CVD: Primary Care Intelligence
Packs
June 2017
Version 1
NHS Ealing CCG
Contents 1. Introduction 3
2. CVD prevention
• The narrative 11
• The data 13
3. Hypertension
• The narrative 16
• The data 17
4. Stroke
• The narrative 27
• The data 28
5. Diabetes
• The narrative 42
• The data 43
6. Kidney
• The narrative 53
• The data 54
7. Heart
• The narrative 65
• The data 66
8. Outcomes 82
9. Appendix 88
2
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CVD: Primary Care Intelligence Packs
3
Introduction
CVD: Primary Care Intelligence Packs
4
This intelligence pack has been compiled by GPs and nurses and pharmacists in
the Primary Care CVD Leadership Forum in collaboration with the National
Cardiovascular Intelligence Network
Matt Kearney Sarit Ghosh Kathryn Griffith
George Kassianos Jo Whitmore Matthew Fay
Chris Harris Jan Procter-King Yassir Javaid
Ivan Benett Ruth Chambers Ahmet Fuat
Mike Kirby Peter Green Kamlesh Khunti
Helen Williams Quincy Chuhka Sheila McCorkindale
Nigel Rowell Ali Morgan Stephen Kirk
Sally Christie Clare Hawley Paul Wright
Bruce Taylor Mike Knapton John Robson
Richard Mendelsohn Chris Arden David Fitzmaurice
CVD: Primary Care Intelligence Packs
Local intelligence as a tool for clinicians and commissioners
to improve outcomes for our patients
Why should we use this CVD Intelligence Pack
The high risk conditions for cardiovascular disease (CVD) - such as hypertension, atrial fibrillation, high cholesterol,
diabetes, non-diabetic hyperglycaemia and chronic kidney disease - are the low hanging fruit for prevention in the NHS
because in each case late diagnosis and suboptimal treatment is common and there is substantial variation. High
quality primary care is central to improving outcomes in CVD because primary care is where much prevention and
most diagnosis and treatment is delivered.
This cardiovascular intelligence pack is a powerful resource for stimulating local conversations about quality
improvement in primary care. Across a number of vascular conditions, looking at prevention, diagnosis, care and
outcomes, the data allows comparison between clinical commissioning groups (CCGs) and between practices.
This is not about performance management because we know that variation can have more than one interpretation.
But patients have a right to expect that we will ask challenging questions about how the best practices are achieving
the best, what average or below average performers could do differently, and how they could be supported to perform
as well as the best.
How to use the CVD intelligence pack
The intelligence pack has several sections – CVD prevention, hypertension, stroke and atrial fibrillation (AF), diabetes,
kidney disease, heart disease and heart failure. Each section has one slide of narrative that makes the case and asks
some questions. This is followed by data for a number of indicators, each with benchmarked comparison between
CCGs and between practices.
Use the pack to identify where there is variation that needs exploring and to start asking challenging questions about
where and how quality could be improved. We suggest you then develop a local action plan for quality improvement –
this might include establishing communities of practice to build clinical leadership, systematic local audit to get a better
understanding of the gaps in care and outcomes, and developing new models of care that mobilise the wider primary
care team to reduce burden on general practice.
5 CVD: Primary Care Intelligence Packs
6
Data and methods
This slide pack compares the clinical commissioning group (CCG) with CCGs in its strategic transformation plan (STP) and
England. Where a CCG is in more than one STP, it has been allocated to the STP with the greatest geographical or
population coverage. The slide pack also compares the CCG to its 10 most similar CCGs in terms of demography, ethnicity
and deprivation. For information on the methodology used to calculate the 10 most similar CCGs please go to:
http://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/
The 10 most similar CCGs to NHS Ealing CCG are:
NHS Hounslow CCG
NHS Brent CCG
NHS Waltham Forest CCG
NHS Merton CCG
NHS Redbridge CCG
NHS Hillingdon CCG
NHS Sandwell and West Birmingham CCG
NHS Harrow CCG
NHS Leicester City CCG
NHS Birmingham South and Central CCG
The majority of data used in the packs is taken from the 2015/16 Quality and Outcomes Framework (QOF). Where this is
not the case, this is indicated in the slide. All GP practices that were included in the 2015/16 QOF are included. Full
source data are shown in the appendix.
For the majority of indicators, the additional number of people that would be treated if all practices were to achieve as well
as the average of the top achieving practices is calculated. This is calculated by taking an average of the intervention rates
(ie the denominator includes exceptions) for the best 50% of practices in the CCG and applying this rate to all practices in
the CCG. Note, this number is not intended to be proof of a realisable improvement; rather it gives an indication of the
magnitude of available opportunity.
CVD: Primary Care Intelligence Packs
Benchmarking is helpful because it highlights
variation.
Of course it has long been acknowledged that some
variation is inevitable in the healthcare and outcomes
experienced by patients.
But John Wennberg, who has championed research
into clinical variation over four decades and who
founded the pioneering Dartmouth Atlas of Health
Care, concluded that much variation is unwarranted –
ie it cannot be explained on the basis of illness,
medical evidence, or patient preference, but is
accounted for by the willingness and ability of doctors
to offer treatment.
Benchmarking may not be conclusive. Its strength lies not in
the answers it provides but in the questions it generates for
CCGs and practices.
For example:
1. How much variation is there in detection, management,
exception reporting and outcomes?
2. How many people would benefit if average performers
improved to the level of the best performers?
3. How many people would benefit if the lowest performers
matched the achievement of the average?
4. What are better performers doing differently in the way
they provide services in order to achieve better outcomes?
5. How can the CCG support low and average performers to
help them match the achievement of the best?
6. How can we build clinical leadership to drive quality
improvement?
A key observation about benchmarking data is
that it does not tell us why there is variation. Some of the
variation may be explained by population or case mix and
some may be unwarranted. We will not know unless we
investigate.
The variation that exists between
demographically similar CCGs and
between practices illustrates the local
potential to improve care and outcomes
for our patients
There are legitimate reasons for exception reporting. But …….
Excepting patients from indicators puts them at risk of not receiving optimal care and of having worse outcomes. It is also
likely to increase health inequalities. The substantial variation seen in exception reporting for some indicators suggests
that some practices are more effective than others at reaching their whole population. Benchmarking exception reporting
allows us to identify the practices that need support to implement the strategies adopted by low excepting practices.
Why does variation matter?
7
Cluster methodology: your most similar practices
Each practice has been grouped on the basis of demographic data into
15 national clusters. These demographic factors cover:
• deprivation (practice level)
• age profile (% < 5, % < 18, % 15-24, % 65+, % 75+, % 85+)
• ethnicity (% population of white ethnicity)
• practice population side
These demographic factors closely align with those used to calculate
the “Similar 10 CCGs”.
These demographic factors have been used to compare practices with
similar populations to account for potential factors which may drive
variation. Some local interpretation will need to be applied to the data
contained within the packs as practices with significant outlying
population characteristics e.g. university populations or care home
practices will need further contextualisation.
Further detailed information including full technical methodology and a
full PDF report on each of the 15 practice clusters is available here:
https://github.com/julianflowers/geopractice.
8 CVD: Primary Care Intelligence Packs
7
9
22
21
17
31
14
15
12
9
3
5
1
1
1
-20%-15%-10%-5%0%5%
WELLINGTON ROAD SURGERY
EMERSONS GREEN MEDICAL CENTRE
LEAP VALLEY MEDICAL CENTRE
CHRISTCHURCH FAMILY MEDICAL CENTRE
CONISTON MEDICAL PRACTICE
FROME VALLEY MEDICAL CENTRE
ST MARY STREET SURGERY
KINGSWOOD HEALTH CENTRE
CONCORD MEDICAL CENTRE
KENNEDY WAY SURGERY
BRADLEY STOKE SURGERY
THE WILLOW SURGERY
CLOSE FARM SURGERY
PILNING SURGERY
COURTSIDE SURGERY
ALMONDSBURY SURGERY
STOKE GIFFORD MEDICAL CENTRE
ORCHARD MEDICAL CENTRE
WEST WALK SURGERY
THORNBURY HEALTH CENTRE - BURNEY
The performance of every practice in the GP cluster contributes to the average of the top performing
50% of practices to form a benchmark.
The difference between the benchmark and the selected practices is displayed on this chart. The benchmark will
most likely be different for different practices as they are in different clusters, so the difference is the key measure
here. If the practice performance is below the benchmark, the difference is applied to the denominator plus
exceptions to demonstrate potential gains on a practice basis. The potential gains on a CCG basis are calculated
based on the difference between the top 5 performing closest CCGs and the selected CCG, applied to the
denominator plus exceptions.
Cluster methodology: calculating potential gains
Raw difference between the
practice value
and the average of the
highest or lowest 50% of
similar cluster practices
Potential opportunity if
the practice value was
to move to the average
of the highest 50% of
similar cluster practices
Potential opportunity if the
CCG value were to move
to the average of the top 5
performing closest CCGs
9 CVD: Primary Care Intelligence Packs
CVD prevention
10 CVD: Primary Care Intelligence Packs
CVD prevention “The NHS needs a radical upgrade
in prevention if it is to be
sustainable”
5 year Forward View 2014
The size of the prevention problem
• 2/3 of adults are obese or overweight
• 1/3 of adults are physically inactive
• average smoking prevalence is 17% but is much
higher in some communities
• in high risk conditions like atrial fibrillation, high blood
pressure, diabetes and high ten year CVD risk score,
up to half of all people do not receive preventive
treatments that are known to be highly effective at
preventing heart attacks and strokes
• around 90% of people with familial hypercholestero-
laemia are undiagnosed and untreated despite their
average 10 year reduction in life expectancy
This is because England faces an epidemic of largely
preventable non-communicable diseases, such as heart
disease and stroke, cancer, Type 2 diabetes and liver disease.
The Global Burden of Disease Study (next slide) shows us that
the leading causes of premature mortality include diet,
tobacco, obesity, raised blood pressure, physical inactivity and
raised cholesterol. The radical upgrade in prevention needs
population-level approaches. But it also needs interventions in
primary care for individuals with behavioural and clinical risk
factors.
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12%
Unsafe water/ sanitation/ handwashing
Unsafe sex
Other environmental risks
Sexual abuse and violence
Child and maternal malnutrition
Low bone mineral density
Air pollution
Occupational risks
Low physical activity
Low glomerular filtration rate
High total cholesterol
High fasting plasma glucose
Alcohol and drug use
High systolic blood pressure
High body-mass index
Tobacco smoke
Dietary risks
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
Percent of total disability-adjusted life-years (DALYs)
Social prescribing and wellbeing hubs offer new
models for supporting behaviour change while reducing
burden on general practice.
The NHS Health Check is a systematic approach to
identifying local people at high risk of CVD, offering
behaviour change support and early detection of the
high risk but often undiagnosed conditions such as
hypertension, atrial fibrillation, CKD, diabetes and pre-
diabetes.
Question: What proportion of our local eligible
population is receiving the NHS Health Check and how
effective is the follow-up management of their clinical
risk factors in primary care?
11 11 CVD: Primary Care Intelligence Packs
Global Burden of Disease Study 2015
Risk Factors for premature death and disability caused by CVD in England, expressed as a percentage of total disability-adjusted life-years
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%
Other environmental risks
Low glomerular filtration rate
Air pollution
Low physical activity
High fasting plasma glucose
Tobacco smoke
High body-mass index
High total cholesterol
Dietary risks
High systolic blood pressure
Percentage of total CVD disability-adjusted life-years (DALYs)
12 CVD: Primary Care Intelligence Packs
12.9%
13.6%
15.5%
15.5%
16.2%
16.3%
16.9%
18.6%
18.7%
19.7%
19.8%
0% 5% 10% 15% 20% 25%
NHS Harrow CCG
NHS Redbridge CCG
NHS Ealing CCG
NHS Merton CCG
NHS Hounslow CCG
NHS Hillingdon CCG
NHS Brent CCG
NHS Leicester City CCG
NHS Birmingham South and Central CCG
NHS Waltham Forest CCG
NHS Sandwell and West Birmingham CCG
13
Estimated smoking prevalence (QOF) by CCG
Comparison with demographically similar CCGs
Note: It has been found that the proportion of
patients recorded as smokers correlates well
with IHS smoking prevalence and is a good
estimate of the actual smoking prevalence in
local areas,
http://bmjopen.bmj.com/content/4/7/e005217.abs
tract
Definition: denominator of QOF clinical indicator
SMOKE004 ( number of patients 15+ who are
recorded as current smokers) divided by GP
practice’s estimated number of patients 15+
CVD: Primary Care Intelligence Packs
• prevalence of 15.5% in NHS Ealing
CCG
4.6%
6.9%
7.0%
7.0%
7.9%
7.9%
9.0%
9.1%
9.4%
9.6%
9.9%
10.3%
10.8%
10.8%
11.0%
11.7%
11.7%
12.3%
12.8%
13.0%
13.1%
13.6%
13.8%
13.9%
13.9%
14.0%
14.3%
14.5%
14.5%
14.9%
15.1%
15.1%
15.4%
16.1%
16.3%
16.4%
16.5%
16.7%
16.7%
16.9%
17.0%
17.0%
17.1%
17.2%
17.2%
17.2%
17.3%
17.3%
17.4%
17.4%
17.8%
18.0%
18.0%
18.2%
18.3%
18.4%
18.5%
18.7%
19.1%
19.2%
19.4%
19.6%
19.8%
19.8%
19.9%
19.9%
20.3%
20.4%
20.5%
20.8%
20.9%
21.0%
21.4%
21.5%
21.5%
22.1%
23.0%
23.8%
24.8%
0% 5% 10% 15% 20% 25% 30%
THE SALUJA CLINIC E85663
THE TOWN SURGERY E85721
HAMMOND ROAD SURGERY E85090
NURSING HOME SERVICES Y04225
THE SOUTHALL MEDICAL CTR. E85633
GURU NANAK MEDICAL CENTRE E85121
SOMERSET FHP O Y01221
JUBILEE GARDENS MEDICAL CENTRE E85745
THE BEDFORD PARK SURGERY E85066
DR SIVANESAN & PARTNER E85083
BELMONT MEDICAL CENTRE E85049
LADY MARGARET ROAD MEDICAL CENTRE E85103
FEATHERSTONE ROAD HEALTH CENTRE Y02342
SUNRISE MEDICAL CENTRE E85656
QUEENS WALK PRACTICE E85057
THE CORFTON ROAD SURGERY E85123
MEADOW VIEW E85643
MEDICAL CENTRE E85096
KS MEDICAL CENTRE E85012
THE MWH PRACTICE E85119
NORTHFIELDS SURGERY E85014
THE BOILEAU ROAD SURGERY E85694
THE ALLENDALE ROAD SURGERY E84059
THE NORTHCOTE MEDICAL CENTRE E85733
ELTHORNE PARK SURGERY E85628
SOMERSET MEDICAL CENTRE E85623
WELCOME PRACTICE E85061
THE PITSHANGER LANE SURGERY E85714
DORMERS WELLS MEDICAL CENTRE E85682
ST.GEORGES MEDICAL CTR. E85743
WATERSIDE MEDICAL CENTRE E85006
ALLENBY CLINIC E85105
THE ARGYLE SURGERY E85120
THE FLORENCE ROAD SURGERY E85122
HANWELL HEALTH CENTRE (STEWART) E85013
THE LYNWOOD SURGERY E85740
EASTMEAD AVENUE SURGERY E85046
GORDON HOUSE SURGERY E85026
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
THE GROVE MEDICAL PRACTICE E85725
PERIVALE MEDICAL CLINIC E85111
THE CUCKOO LANE PRACTICE E85116
GOODCARE PRACTICE E85712
HILLVIEW SURGERY E85054
THE AVENUE SURGERY E85099
CHISWICK FAMILY PRACTICE E85130
MATTOCK LANE HEALTH CENTRE E85726
BRUNSWICK ROAD MED.CTR. E85091
HILLCREST SURGERY E85028
THE MANSELL ROAD PRACTICE E85129
CHEPSTOW GARDENS MEDICAL CENTRE E85023
THE VALE SURGERY E85635
MANDEVILLE MEDICAL CENTRE E85108
EALING PARK HEALTH CENTRE E85657
THE BARNABAS MEDICAL CTRE E85127
ISLIP MANOR MEDICAL CENTRE E85098
THE MILL HILL SURGERY E85107
YEADING MEDICAL CENTRE E85021
NORTHOLT FAMILY PRACTICE E85723
OLDFIELD FAMILY PRACTICE E85069
GREENFORD ROAD MED.CTR. E85050
THE ACTON HEALTH CENTRE E85109
THE HORN LANE SURGERY E85677
CROWN STREET SURGERY E85019
THE MEDICAL CENTRE E85053
RIBCHESTER MEDICAL CENTRE E85728
GROSVENOR HOUSE SURGERY E85034
BROADMEAD SURGERY E85715
ACTON LANE MEDICAL CENTRE E85687
CLOISTER ROAD SURGERY E85680
ACTON TOWN MEDICAL CENTRE E85617
ELMBANK SURGERY E85088
ELMTREES SURGERY E85112
HANWELL HEALTH CENTRE (NAISH) E85041
GREENFORD AVENUE FHP E85051
WEST END SURGERY E85064
THE CHURCHFIELD ROAD SURGERY E85640
WESTERN AVENUE SURGERY E85630
THE BURLINGTON GARDENS SURGERY E85705
GP Practice CCG
14
Estimated smoking prevalence (QOF) by GP practice
Note: This method is thought to be a reasonably
robust method in estimating smoking prevalence
for the majority of GP practices. However,
caution is advised for extreme estimates of
smoking prevalence and those with high
numbers of smoking status not recorded and
exceptions.
CVD: Primary Care Intelligence Packs
• 53,762 people who are recorded as
smokers in NHS Ealing CCG
• GP practice range: 4.6% to 24.8%
Hypertension
15 CVD: Primary Care Intelligence Packs
16
The Missing Millions On average, each CCG in England has 26,000 residents with
undiagnosed hypertension – these individuals are unaware of
their increased cardiovascular risk and are untreated.
What might help? • support practices to share audit data and systematically
identify gaps and opportunities for improved detection and
management of hypertension
• work with practices and local authorities to maximise
uptake and follow up in the NHS Health Check
• support access to self-test BP stations in waiting rooms
and to ambulatory blood pressure monitoring.
• commission community pharmacists to offer blood
pressure measurement, diagnosis and management
support, including support for adherence to medication
What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement
and exception reporting?
2. how many people would benefit if all practices performed
as well as the best?
3. how can we support practices who are average or below
average to perform as well as the best in:
• detection of hypertension
• management of hypertension What do we know? • at least half of all heart attacks and strokes are
caused by high blood pressure and it is a major risk
factor for chronic kidney disease and cognitive decline
• treatment is very effective – every 10mmHg reduction
in systolic blood pressure lowers risk of heart attack
and stroke by 20%
• despite this 4 out of 10 adults with hypertension, over
5 and a half million people in England, remain
undiagnosed
• and even when the condition is identified, treatment is
often suboptimal, with blood pressure poorly
controlled in about 1 out of 3 individuals
Hypertension
High blood pressure is common and costly • it affects around a quarter of all adults
• the NHS costs of hypertension are around £2bn
• social costs are probably considerably higher
CVD: Primary Care Intelligence Packs
The Global Burden of Disease
Study confirmed high blood pressure as
a leading cause of premature death
and disability
0.59
0.48
0.49
0.51
0.57
0.57
0.58
0.58
0.59
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
England
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hammersmith And Fulham CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Harrow CCG
Ratio
0.59
0.48
0.49
0.51
0.57
0.57
0.58
0.58
0.59
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
England
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hammersmith And Fulham CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Harrow CCG
Ratio
17
Hypertension observed prevalence compared with expected prevalence by CCG
Comparison with CCGs in the STP
CVD: Primary Care Intelligence Packs
Note: this slide shows Hypertension prevalence
estimates created using data from QOF
hypertension registers 2014/15 and
Undiagnosed hypertension estimates for adults
16 years and older. 2014. Department of Primary
Care & Public Health, Imperial College London
• the ratio of those diagnosed with
hypertension versus those expected
to have hypertension is 0.57. This
compares to 0.59 for England
• this suggests that 57% of people with
hypertension have been diagnosed
0.53
0.56
0.56
0.57
0.57
0.57
0.57
0.58
0.58
0.59
0.59
0% 10% 20% 30% 40% 50% 60% 70%
NHS Merton CCG
NHS Birmingham South and Central CCG
NHS Waltham Forest CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS Leicester City CCG
NHS Redbridge CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Harrow CCG
NHS Sandwell and West Birmingham CCG
18
Hypertension observed prevalence compared with expected prevalence by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
0.31
0.31
0.32
0.37
0.38
0.38
0.41
0.44
0.44
0.45
0.45
0.45
0.45
0.45
0.46
0.47
0.47
0.48
0.48
0.49
0.49
0.50
0.50
0.51
0.51
0.51
0.51
0.51
0.51
0.51
0.53
0.53
0.53
0.54
0.54
0.55
0.55
0.55
0.56
0.56
0.56
0.57
0.57
0.57
0.57
0.58
0.58
0.59
0.59
0.59
0.59
0.60
0.60
0.60
0.63
0.63
0.64
0.66
0.66
0.66
0.67
0.68
0.69
0.69
0.70
0.71
0.71
0.71
0.72
0.73
0.77
0.78
0.79
0.79
0.81
0.83
0.84
0.87
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
THE HORN LANE SURGERY E85677
FEATHERSTONE ROAD HEALTH CENTRE Y02342
THE VALE SURGERY E85635
THE BEDFORD PARK SURGERY E85066
THE CORFTON ROAD SURGERY E85123
ACTON LANE MEDICAL CENTRE E85687
THE MILL HILL SURGERY E85107
THE CHURCHFIELD ROAD SURGERY E85640
THE FLORENCE ROAD SURGERY E85122
BROADMEAD SURGERY E85715
HANWELL HEALTH CENTRE (STEWART) E85013
THE BURLINGTON GARDENS SURGERY E85705
GORDON HOUSE SURGERY E85026
ELTHORNE PARK SURGERY E85628
CLOISTER ROAD SURGERY E85680
ACTON TOWN MEDICAL CENTRE E85617
THE BOILEAU ROAD SURGERY E85694
EALING PARK HEALTH CENTRE E85657
CHISWICK FAMILY PRACTICE E85130
HANWELL HEALTH CENTRE (NAISH) E85041
WATERSIDE MEDICAL CENTRE E85006
PERIVALE MEDICAL CLINIC E85111
THE ARGYLE SURGERY E85120
QUEENS WALK PRACTICE E85057
THE AVENUE SURGERY E85099
NORTHFIELDS SURGERY E85014
THE GROVE MEDICAL PRACTICE E85725
HILLCREST SURGERY E85028
WESTERN AVENUE SURGERY E85630
MATTOCK LANE HEALTH CENTRE E85726
THE ACTON HEALTH CENTRE E85109
THE PITSHANGER LANE SURGERY E85714
GOODCARE PRACTICE E85712
THE LYNWOOD SURGERY E85740
BRUNSWICK ROAD MED.CTR. E85091
THE ALLENDALE ROAD SURGERY E84059
THE MEDICAL CENTRE E85053
THE SALUJA CLINIC E85663
HILLVIEW SURGERY E85054
DORMERS WELLS MEDICAL CENTRE E85682
GREENFORD ROAD MED.CTR. E85050
THE SOUTHALL MEDICAL CTR. E85633
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
CROWN STREET SURGERY E85019
THE BARNABAS MEDICAL CTRE E85127
GURU NANAK MEDICAL CENTRE E85121
ISLIP MANOR MEDICAL CENTRE E85098
MANDEVILLE MEDICAL CENTRE E85108
THE CUCKOO LANE PRACTICE E85116
OLDFIELD FAMILY PRACTICE E85069
ELMTREES SURGERY E85112
GREENFORD AVENUE FHP E85051
THE MANSELL ROAD PRACTICE E85129
ST.GEORGES MEDICAL CTR. E85743
ALLENBY CLINIC E85105
MEDICAL CENTRE E85096
NORTHOLT FAMILY PRACTICE E85723
EASTMEAD AVENUE SURGERY E85046
ELMBANK SURGERY E85088
SOMERSET FHP O Y01221
GROSVENOR HOUSE SURGERY E85034
YEADING MEDICAL CENTRE E85021
WEST END SURGERY E85064
HAMMOND ROAD SURGERY E85090
THE TOWN SURGERY E85721
CHEPSTOW GARDENS MEDICAL CENTRE E85023
WELCOME PRACTICE E85061
JUBILEE GARDENS MEDICAL CENTRE E85745
BELMONT MEDICAL CENTRE E85049
RIBCHESTER MEDICAL CENTRE E85728
SOMERSET MEDICAL CENTRE E85623
THE NORTHCOTE MEDICAL CENTRE E85733
SUNRISE MEDICAL CENTRE E85656
KS MEDICAL CENTRE E85012
THE MWH PRACTICE E85119
MEADOW VIEW E85643
DR SIVANESAN & PARTNER E85083
LADY MARGARET ROAD MEDICAL CENTRE E85103
Ratio
GP practice CCG
19
Hypertension observed prevalence compared with expected prevalence by GP practice
• it is estimated that there are 36,218
people with undiagnosed
hypertension in NHS Ealing CCG
• GP practice range of observed to
expected hypertension prevalence
0.31 to 0.87
CVD: Primary Care Intelligence Packs
79.6%
74.3%
75.3%
77.6%
78.7%
78.8%
79.7%
79.8%
80.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
England
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS Hillingdon CCG
NHS Brent CCG
NHS Harrow CCG
79.6%
74.3%
75.3%
77.6%
78.7%
78.8%
79.7%
79.8%
80.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
England
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS Hillingdon CCG
NHS Brent CCG
NHS Harrow CCG
20
Percentage of patients with hypertension whose last blood pressure reading (measured in
the preceding 12 months) is 150/90 mmHg or less by CCG
Comparison with CCGs in the STP
*Using QOF clinical indicator HYP006
denominator plus exceptions
• 49,249 people with hypertension
(diagnosed)* in NHS Ealing CCG
• 38,739 (78.7%) people whose blood
pressure is <= 150/90
• 2,174 (4.4%) people who are
excepted from optimal control
• 8,336 (16.9%) additional people
whose blood pressure is not <=
150/90
CVD: Primary Care Intelligence Packs
77.3%
77.7%
78.3%
78.5%
78.7%
78.8%
79.1%
79.7%
79.8%
80.2%
80.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
NHS Merton CCG
NHS Waltham Forest CCG
NHS Redbridge CCG
NHS Sandwell and West Birmingham CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS Leicester City CCG
NHS Hillingdon CCG
NHS Brent CCG
NHS Birmingham South and Central CCG
NHS Harrow CCG
21
Percentage of patients with hypertension whose last blood pressure reading (measured in
the preceding 12 months) is 150/90 mmHg or less by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
9
16
6
45
64
69
41
122
13
51
80
82
148
83
62
58
167
49
58
111
105
68
71
196
112
232
51
96
122
141
148
141
158
166
126
221
262
264
186
62
85
74
204
97
37
61
165
192
210
112
137
252
168
151
85
65
138
290
197
213
228
131
194
98
69
194
254
165
253
214
96
114
146
398
278
150
68
118
147
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
RIBCHESTER MEDICAL CENTRE E85728
THE TOWN SURGERY E85721
THE BURLINGTON GARDENS SURGERY E85705
CHISWICK FAMILY PRACTICE E85130
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
ELMBANK SURGERY E85088
ALLENBY CLINIC E85105
KS MEDICAL CENTRE E85012
ACTON LANE MEDICAL CENTRE E85687
HANWELL HEALTH CENTRE (STEWART) E85013
NORTHOLT FAMILY PRACTICE E85723
OLDFIELD FAMILY PRACTICE E85069
DR SIVANESAN & PARTNER E85083
CHEPSTOW GARDENS MEDICAL CENTRE E85023
MATTOCK LANE HEALTH CENTRE E85726
THE AVENUE SURGERY E85099
GROSVENOR HOUSE SURGERY E85034
THE BEDFORD PARK SURGERY E85066
PERIVALE MEDICAL CLINIC E85111
THE CUCKOO LANE PRACTICE E85116
SUNRISE MEDICAL CENTRE E85656
ST.GEORGES MEDICAL CTR. E85743
WATERSIDE MEDICAL CENTRE E85006
CROWN STREET SURGERY E85019
GOODCARE PRACTICE E85712
QUEENS WALK PRACTICE E85057
THE NORTHCOTE MEDICAL CENTRE E85733
THE MEDICAL CENTRE E85053
WEST END SURGERY E85064
DORMERS WELLS MEDICAL CENTRE E85682
THE SOUTHALL MEDICAL CTR. E85633
THE GROVE MEDICAL PRACTICE E85725
HAMMOND ROAD SURGERY E85090
EALING PARK HEALTH CENTRE E85657
ELMTREES SURGERY E85112
THE BARNABAS MEDICAL CTRE E85127
GURU NANAK MEDICAL CENTRE E85121
GORDON HOUSE SURGERY E85026
THE SALUJA CLINIC E85663
WESTERN AVENUE SURGERY E85630
BROADMEAD SURGERY E85715
THE CHURCHFIELD ROAD SURGERY E85640
NORTHFIELDS SURGERY E85014
SOMERSET FHP O Y01221
BRUNSWICK ROAD MED.CTR. E85091
SOMERSET MEDICAL CENTRE E85623
ELTHORNE PARK SURGERY E85628
HILLCREST SURGERY E85028
GREENFORD ROAD MED.CTR. E85050
WELCOME PRACTICE E85061
THE MILL HILL SURGERY E85107
THE MWH PRACTICE E85119
CLOISTER ROAD SURGERY E85680
MANDEVILLE MEDICAL CENTRE E85108
THE ACTON HEALTH CENTRE E85109
ACTON TOWN MEDICAL CENTRE E85617
HANWELL HEALTH CENTRE (NAISH) E85041
THE FLORENCE ROAD SURGERY E85122
THE ARGYLE SURGERY E85120
MEDICAL CENTRE E85096
GREENFORD AVENUE FHP E85051
THE ALLENDALE ROAD SURGERY E84059
BELMONT MEDICAL CENTRE E85049
ISLIP MANOR MEDICAL CENTRE E85098
THE HORN LANE SURGERY E85677
MEADOW VIEW E85643
JUBILEE GARDENS MEDICAL CENTRE E85745
LADY MARGARET ROAD MEDICAL CENTRE E85103
YEADING MEDICAL CENTRE E85021
THE MANSELL ROAD PRACTICE E85129
THE VALE SURGERY E85635
FEATHERSTONE ROAD HEALTH CENTRE Y02342
THE CORFTON ROAD SURGERY E85123
HILLVIEW SURGERY E85054
EASTMEAD AVENUE SURGERY E85046
NURSING HOME SERVICES Y04225
THE LYNWOOD SURGERY E85740
THE BOILEAU ROAD SURGERY E85694
THE PITSHANGER LANE SURGERY E85714
No treatment Exceptions reported
22
Percentage of patients with hypertension whose last blood pressure reading
(measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
• in total, including exceptions, there
are 10,510 people whose blood
pressure is not <= 150/90
• GP practice range: 2.8% to 39.6%
CVD: Primary Care Intelligence Packs
66.5%
65.4%
70.1%
71.6%
73.4%
76.0%
78.4%
83.4%
84.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
England
NHS Harrow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Hammersmith And Fulham CCG
66.5%
65.4%
70.1%
71.6%
73.4%
76.0%
78.4%
83.4%
84.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
England
NHS Harrow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Hammersmith And Fulham CCG
23
New diagnosis of hypertension who have been given a CVD risk assessment whose
CVD risk exceeds 20% and treated with statins by CCG
Comparison with CCGs in the STP
• 175 people with a new diagnosis* of
hypertension with a CVD risk of 20%
or higher in NHS Ealing CCG
• 146 (83.4%) people who are currently
treated with statins
• 27 (15.4%) people who are exempted
from treatment with statins
• 2 (1.1%) additional people who are
not currently treated with statins
*Using the QOF clinical indicator CVD-PP001
denominator plus exceptions
CVD: Primary Care Intelligence Packs
65.4%
69.5%
70.1%
70.7%
71.6%
72.0%
72.5%
78.4%
79.4%
80.2%
83.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
NHS Harrow CCG
NHS Leicester City CCG
NHS Brent CCG
NHS Birmingham South and Central CCG
NHS Hillingdon CCG
NHS Merton CCG
NHS Waltham Forest CCG
NHS Hounslow CCG
NHS Sandwell and West Birmingham CCG
NHS Redbridge CCG
NHS Ealing CCG
65.4%
69.5%
70.1%
70.7%
71.6%
72.0%
72.5%
78.4%
79.4%
80.2%
83.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
NHS Harrow CCG
NHS Leicester City CCG
NHS Brent CCG
NHS Birmingham South and Central CCG
NHS Hillingdon CCG
NHS Merton CCG
NHS Waltham Forest CCG
NHS Hounslow CCG
NHS Sandwell and West Birmingham CCG
NHS Redbridge CCG
NHS Ealing CCG
24
New diagnosis of hypertension who have been given a CVD risk assessment whose
CVD risk exceeds 20% and treated with statins by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
1
1
1
2
4
1
1
1
2
2
1
1
1
1
1
1
3
1
1
2
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
WATERSIDE MEDICAL CENTRE E85006
MEDICAL CENTRE E85096
ISLIP MANOR MEDICAL CENTRE E85098
THE HORN LANE SURGERY E85677
THE LYNWOOD SURGERY E85740
SOMERSET FHP O Y01221
NURSING HOME SERVICES Y04225
ST.GEORGES MEDICAL CTR. E85743
THE NORTHCOTE MEDICAL CENTRE E85733
RIBCHESTER MEDICAL CENTRE E85728
THE GROVE MEDICAL PRACTICE E85725
NORTHOLT FAMILY PRACTICE E85723
THE TOWN SURGERY E85721
BROADMEAD SURGERY E85715
THE PITSHANGER LANE SURGERY E85714
GOODCARE PRACTICE E85712
THE BURLINGTON GARDENS SURGERY E85705
THE BOILEAU ROAD SURGERY E85694
ACTON LANE MEDICAL CENTRE E85687
DORMERS WELLS MEDICAL CENTRE E85682
CLOISTER ROAD SURGERY E85680
SUNRISE MEDICAL CENTRE E85656
MEADOW VIEW E85643
THE CHURCHFIELD ROAD SURGERY E85640
THE VALE SURGERY E85635
THE SOUTHALL MEDICAL CTR. E85633
SOMERSET MEDICAL CENTRE E85623
ACTON TOWN MEDICAL CENTRE E85617
CHISWICK FAMILY PRACTICE E85130
THE MANSELL ROAD PRACTICE E85129
GURU NANAK MEDICAL CENTRE E85121
THE MWH PRACTICE E85119
ELMTREES SURGERY E85112
PERIVALE MEDICAL CLINIC E85111
THE ACTON HEALTH CENTRE E85109
MANDEVILLE MEDICAL CENTRE E85108
ALLENBY CLINIC E85105
LADY MARGARET ROAD MEDICAL CENTRE E85103
THE AVENUE SURGERY E85099
BRUNSWICK ROAD MED.CTR. E85091
HAMMOND ROAD SURGERY E85090
ELMBANK SURGERY E85088
DR SIVANESAN & PARTNER E85083
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
OLDFIELD FAMILY PRACTICE E85069
HILLVIEW SURGERY E85054
THE MEDICAL CENTRE E85053
GREENFORD ROAD MED.CTR. E85050
BELMONT MEDICAL CENTRE E85049
EASTMEAD AVENUE SURGERY E85046
HANWELL HEALTH CENTRE (NAISH) E85041
GORDON HOUSE SURGERY E85026
CHEPSTOW GARDENS MEDICAL CENTRE E85023
YEADING MEDICAL CENTRE E85021
CROWN STREET SURGERY E85019
NORTHFIELDS SURGERY E85014
HANWELL HEALTH CENTRE (STEWART) E85013
KS MEDICAL CENTRE E85012
THE ALLENDALE ROAD SURGERY E84059
JUBILEE GARDENS MEDICAL CENTRE E85745
THE FLORENCE ROAD SURGERY E85122
FEATHERSTONE ROAD HEALTH CENTRE Y02342
THE BARNABAS MEDICAL CTRE E85127
HILLCREST SURGERY E85028
EALING PARK HEALTH CENTRE E85657
WESTERN AVENUE SURGERY E85630
THE MILL HILL SURGERY E85107
ELTHORNE PARK SURGERY E85628
THE CUCKOO LANE PRACTICE E85116
THE SALUJA CLINIC E85663
THE CORFTON ROAD SURGERY E85123
THE ARGYLE SURGERY E85120
THE BEDFORD PARK SURGERY E85066
WEST END SURGERY E85064
GREENFORD AVENUE FHP E85051
QUEENS WALK PRACTICE E85057
MATTOCK LANE HEALTH CENTRE E85726
WELCOME PRACTICE E85061
GROSVENOR HOUSE SURGERY E85034
No treatment Exceptions reported
25
New diagnosis of hypertension who have been given a CVD risk assessment whose
CVD risk exceeds 20% and not treated with statins by GP practice
• in total, including exceptions, there
are 29 people who are not treated
with statins
• GP practice range: 0.0% to 100.0%
CVD: Primary Care Intelligence Packs
Stroke
26 CVD: Primary Care Intelligence Packs
27
Only a half of people with known
AF who then suffer a stroke have been
anticoagulated before their stroke.
Stroke is one of the leading causes of
premature death and disability. Stroke is
devastating for individuals and families, and
accounts for a substantial proportion of health
and social care expenditure.
What might help? • increase opportunistic pulse checking especially in over 65s
• support practices to share audit data and systematically
identify gaps and opportunities for improved detection and
management of AF - eg GRASP-AF
• promote systematic use of CHADS-VASC and HASBLED to
ensure those at high risk are offered stroke prevention
• promote systematic use of Warfarin Patient Safety Audit Tool
to ensure optimal time in therapeutic range for people on
warfarin
• develop local consensus statement on risk-benefit balance for
anticoagulants, including the newer treatments (NOACs)
• work with practices and local authorities to maximise uptake
and clinical follow up in the NHS Health Check
• commission community pharmacists to offer pulse checks,
anticoagulant monitoring, and support for adherence to
medication
What questions should we ask in our CCG? 1. for each indicator how wide is the variation in
detection, treatment and exception reporting?
2. how many people would benefit if all practices
performed as well as the best?
3. how can we support practices who are average
and below average to perform as well as the
best in detection of atrial fibrillation and stroke
prevention with anticoagulation.
Atrial fibrillation increases the risk of stroke
by a factor of 5, and strokes caused by AF are
often more severe, with higher mortality and
greater disability.
Anticoagulation reduces the risk of stroke in
people with AF by two thirds.
Despite this, AF is underdiagnosed and under
treated: up to a third of people with AF are
unaware they have the condition and even when
diagnosed inadequate treatment is common –
large numbers do not receive anticoagulants or
have poor anticoagulant control.
Stroke prevention
CVD: Primary Care Intelligence Packs
0.70
0.47
0.58
0.58
0.59
0.61
0.64
0.65
0.65
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
England
NHS Brent CCG
NHS West London CCG
NHS Harrow CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Hillingdon CCG
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
0.70
0.47
0.58
0.58
0.59
0.61
0.64
0.65
0.65
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
England
NHS Brent CCG
NHS West London CCG
NHS Harrow CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Hillingdon CCG
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
28
Atrial fibrillation observed prevalence compared to expected prevalence by CCG
Comparison with CCGs in the STP
Note: This slide compares the prevalence of
atrial fibrillation recorded in QOF in 2015/16 to
the estimated prevalence of atrial fibrillation,
taken from National Cardiovascular Intelligence
Network estimates produced in 2017. The
estimates were developed by applying age-sex
specific prevalence rates as reported by Norberg
et al (2013) to GP population estimates from
NHS Digital. Estimates reported are adjusted for
age and sex of the local population.
• the ratio of those diagnosed with atrial
fibrillation versus those expected to
have atrial fibrillation is 0.61. This
compares to 0.7 for England
• this suggests that 61% of people with
atrial fibrillation have been diagnosed.
CVD: Primary Care Intelligence Packs
0.47
0.50
0.51
0.55
0.58
0.58
0.59
0.60
0.60
0.61
0.64
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
NHS Brent CCG
NHS Redbridge CCG
NHS Waltham Forest CCG
NHS Leicester City CCG
NHS Merton CCG
NHS Harrow CCG
NHS Hounslow CCG
NHS Sandwell and West Birmingham CCG
NHS Birmingham South and Central CCG
NHS Ealing CCG
NHS Hillingdon CCG
29
Atrial fibrillation observed prevalence compared to expected prevalence by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
0.1
0.1
0.2
0.3
0.3
0.3
0.3
0.3
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.6
0.6
0.6
0.6
0.6
0.6
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.7
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
1.0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
THE TOWN SURGERY E85721
ACTON LANE MEDICAL CENTRE E85687
PERIVALE MEDICAL CLINIC E85111
FEATHERSTONE ROAD HEALTH CENTRE Y02342
THE SALUJA CLINIC E85663
THE SOUTHALL MEDICAL CTR. E85633
BRUNSWICK ROAD MED.CTR. E85091
WELCOME PRACTICE E85061
SOMERSET FHP O Y01221
THE LYNWOOD SURGERY E85740
THE NORTHCOTE MEDICAL CENTRE E85733
DORMERS WELLS MEDICAL CENTRE E85682
SUNRISE MEDICAL CENTRE E85656
MEADOW VIEW E85643
THE CHURCHFIELD ROAD SURGERY E85640
GURU NANAK MEDICAL CENTRE E85121
THE MWH PRACTICE E85119
THE ACTON HEALTH CENTRE E85109
LADY MARGARET ROAD MEDICAL CENTRE E85103
ISLIP MANOR MEDICAL CENTRE E85098
HAMMOND ROAD SURGERY E85090
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
WATERSIDE MEDICAL CENTRE E85006
THE ALLENDALE ROAD SURGERY E84059
JUBILEE GARDENS MEDICAL CENTRE E85745
NORTHOLT FAMILY PRACTICE E85723
GOODCARE PRACTICE E85712
THE BOILEAU ROAD SURGERY E85694
THE HORN LANE SURGERY E85677
THE VALE SURGERY E85635
SOMERSET MEDICAL CENTRE E85623
CHISWICK FAMILY PRACTICE E85130
THE ARGYLE SURGERY E85120
ELMTREES SURGERY E85112
MANDEVILLE MEDICAL CENTRE E85108
THE MILL HILL SURGERY E85107
ALLENBY CLINIC E85105
MEDICAL CENTRE E85096
BELMONT MEDICAL CENTRE E85049
KS MEDICAL CENTRE E85012
ST.GEORGES MEDICAL CTR. E85743
WESTERN AVENUE SURGERY E85630
THE BEDFORD PARK SURGERY E85066
THE MEDICAL CENTRE E85053
GREENFORD ROAD MED.CTR. E85050
HANWELL HEALTH CENTRE (STEWART) E85013
NURSING HOME SERVICES Y04225
MATTOCK LANE HEALTH CENTRE E85726
THE GROVE MEDICAL PRACTICE E85725
BROADMEAD SURGERY E85715
EALING PARK HEALTH CENTRE E85657
ACTON TOWN MEDICAL CENTRE E85617
THE BARNABAS MEDICAL CTRE E85127
THE CORFTON ROAD SURGERY E85123
THE FLORENCE ROAD SURGERY E85122
THE CUCKOO LANE PRACTICE E85116
THE AVENUE SURGERY E85099
ELMBANK SURGERY E85088
OLDFIELD FAMILY PRACTICE E85069
WEST END SURGERY E85064
HILLVIEW SURGERY E85054
GORDON HOUSE SURGERY E85026
YEADING MEDICAL CENTRE E85021
CROWN STREET SURGERY E85019
NORTHFIELDS SURGERY E85014
CLOISTER ROAD SURGERY E85680
ELTHORNE PARK SURGERY E85628
THE MANSELL ROAD PRACTICE E85129
DR SIVANESAN & PARTNER E85083
QUEENS WALK PRACTICE E85057
GREENFORD AVENUE FHP E85051
EASTMEAD AVENUE SURGERY E85046
HANWELL HEALTH CENTRE (NAISH) E85041
GROSVENOR HOUSE SURGERY E85034
HILLCREST SURGERY E85028
CHEPSTOW GARDENS MEDICAL CENTRE E85023
THE PITSHANGER LANE SURGERY E85714
Ratio
GP practice CCG
30
Atrial fibrillation observed prevalence compared with expected prevalence by GP practice
• it is estimated that there are 6,944
people with undiagnosed atrial
fibrillation in NHS Ealing CCG
• GP practice range of observed to
expected atrial fibrillation prevalence
0.1 to 1
CVD: Primary Care Intelligence Packs
77.9%
68.3%
69.0%
72.2%
75.9%
75.9%
76.1%
76.4%
76.9%
0% 20% 40% 60% 80% 100%
England
NHS Brent CCG
NHS Harrow CCG
NHS Hillingdon CCG
NHS West London CCG
NHS Ealing CCG
NHS Central London (Westminster) CCG
NHS Hammersmith And Fulham CCG
NHS Hounslow CCG
Optimal management No treatment Exceptions reported
31
In patients with AF with a CHA2DS2-VASc score of 2 or more,
the percentage treated with anti-coagulation therapy by CCG
Comparison with CCGs in the STP
• 3,278 people with atrial fibrillation*
with a CHA2DS2-VASc score >= 2 in
NHS Ealing CCG
• 2,489 (75.9%) people treated with
anti-coagulation therapy
• 358 (10.9%) people who are
exceptions
• 431 (13.1%) additional people with a
recorded CHA2DS2-VASc score >= 2
who are not treated
*Using the QOF clinical indicator AF007
denominator plus exceptions
CVD: Primary Care Intelligence Packs
68.3%
69.0%
72.2%
74.1%
75.5%
75.7%
75.9%
76.9%
77.3%
79.5%
82.2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Brent CCG
NHS Harrow CCG
NHS Hillingdon CCG
NHS Birmingham South and Central CCG
NHS Redbridge CCG
NHS Waltham Forest CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS Merton CCG
NHS Sandwell and West Birmingham CCG
NHS Leicester City CCG
Optimal management No treatment Exceptions reported
32
In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage
treated with anti-coagulation therapy by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
2
1
1
3
3
2
4
2
9
3
10
6
2
5
4
4
13
2
2
15
6
2
7
16
19
13
3
19
5
5
14
14
8
5
4
9
9
9
7
11
35
11
7
3
24
13
11
41
6
10
9
22
4
8
18
7
5
16
13
7
19
27
10
7
17
44
3
4
8
4
20
20
58
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ST.GEORGES MEDICAL CTR. E85743
THE TOWN SURGERY E85721
THE BURLINGTON GARDENS SURGERY E85705
ACTON LANE MEDICAL CENTRE E85687
THE VALE SURGERY E85635
BRUNSWICK ROAD MED.CTR. E85091
GOODCARE PRACTICE E85712
ALLENBY CLINIC E85105
WATERSIDE MEDICAL CENTRE E85006
OLDFIELD FAMILY PRACTICE E85069
MEDICAL CENTRE E85096
SOMERSET FHP O Y01221
MATTOCK LANE HEALTH CENTRE E85726
LADY MARGARET ROAD MEDICAL CENTRE E85103
GREENFORD ROAD MED.CTR. E85050
HANWELL HEALTH CENTRE (STEWART) E85013
THE MANSELL ROAD PRACTICE E85129
WEST END SURGERY E85064
WELCOME PRACTICE E85061
MANDEVILLE MEDICAL CENTRE E85108
CHISWICK FAMILY PRACTICE E85130
THE SOUTHALL MEDICAL CTR. E85633
NORTHFIELDS SURGERY E85014
FEATHERSTONE ROAD HEALTH CENTRE Y02342
THE LYNWOOD SURGERY E85740
GREENFORD AVENUE FHP E85051
THE AVENUE SURGERY E85099
THE NORTHCOTE MEDICAL CENTRE E85733
THE MWH PRACTICE E85119
THE BARNABAS MEDICAL CTRE E85127
GROSVENOR HOUSE SURGERY E85034
EALING PARK HEALTH CENTRE E85657
THE CHURCHFIELD ROAD SURGERY E85640
CROWN STREET SURGERY E85019
SUNRISE MEDICAL CENTRE E85656
MEADOW VIEW E85643
EASTMEAD AVENUE SURGERY E85046
YEADING MEDICAL CENTRE E85021
ELMBANK SURGERY E85088
ELMTREES SURGERY E85112
THE HORN LANE SURGERY E85677
BELMONT MEDICAL CENTRE E85049
THE MEDICAL CENTRE E85053
CHEPSTOW GARDENS MEDICAL CENTRE E85023
HAMMOND ROAD SURGERY E85090
THE PITSHANGER LANE SURGERY E85714
GORDON HOUSE SURGERY E85026
THE CUCKOO LANE PRACTICE E85116
THE MILL HILL SURGERY E85107
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
HILLCREST SURGERY E85028
THE ARGYLE SURGERY E85120
KS MEDICAL CENTRE E85012
QUEENS WALK PRACTICE E85057
WESTERN AVENUE SURGERY E85630
THE ALLENDALE ROAD SURGERY E84059
THE BOILEAU ROAD SURGERY E85694
CLOISTER ROAD SURGERY E85680
SOMERSET MEDICAL CENTRE E85623
THE BEDFORD PARK SURGERY E85066
HILLVIEW SURGERY E85054
BROADMEAD SURGERY E85715
THE ACTON HEALTH CENTRE E85109
HANWELL HEALTH CENTRE (NAISH) E85041
JUBILEE GARDENS MEDICAL CENTRE E85745
THE SALUJA CLINIC E85663
THE GROVE MEDICAL PRACTICE E85725
ELTHORNE PARK SURGERY E85628
DORMERS WELLS MEDICAL CENTRE E85682
ACTON TOWN MEDICAL CENTRE E85617
GURU NANAK MEDICAL CENTRE E85121
THE FLORENCE ROAD SURGERY E85122
ISLIP MANOR MEDICAL CENTRE E85098
RIBCHESTER MEDICAL CENTRE E85728
NORTHOLT FAMILY PRACTICE E85723
PERIVALE MEDICAL CLINIC E85111
DR SIVANESAN & PARTNER E85083
THE CORFTON ROAD SURGERY E85123
NURSING HOME SERVICES Y04225
No treatment Exceptions reported
33
In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated
with anti-coagulation therapy by GP practice
• in total, including exceptions, there
are 789 people with a recorded
CHA2DS2-VASc score >= 2 who are
not treated
• GP practice range: 0.0% to 63.0%
CVD: Primary Care Intelligence Packs
12
12
5
2
2
2
9
3
5
9
-30%-25%-20%-15%-10%-5%0%5%10%15%20%
THE CORFTON ROAD SURGERY
DR SIVANESAN & PARTNER
NORTHOLT FAMILY PRACTICE
PERIVALE MEDICAL CLINIC
RIBCHESTER MEDICAL CENTRE
ISLIP MANOR MEDICAL CENTRE
GURU NANAK MEDICAL CENTRE
ACTON TOWN MEDICAL CENTRE
DORMERS WELLS MEDICAL CENTRE
THE GROVE MEDICAL PRACTICE
OLDFIELD FAMILY PRACTICE
GOODCARE PRACTICE
WATERSIDE MEDICAL CENTRE
ALLENBY CLINIC
THE TOWN SURGERY
ST.GEORGES MEDICAL CTR.
THE BURLINGTON GARDENS SURGERY
THE VALE SURGERY
ACTON LANE MEDICAL CENTRE
BRUNSWICK ROAD MED.CTR.
34 34 CVD: Primary Care Intelligence Packs
In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated
with anti-coagulation therapy by GP practice – opportunities compared to GP cluster
• using the GP cluster method of
calculating potential gains, if each
practice was to achieve as well as the
upper quartile of its national cluster,
then an additional 245 people would
be treated
Details of this methodology are available on slide
9. Click here to view them.
83.8%
80.3%
81.3%
82.9%
82.9%
83.3%
84.2%
84.6%
84.8%
0% 20% 40% 60% 80% 100%
England
NHS Hammersmith And Fulham CCG
NHS West London CCG
NHS Ealing CCG
NHS Central London (Westminster) CCG
NHS Hillingdon CCG
NHS Brent CCG
NHS Hounslow CCG
NHS Harrow CCG
Below 150/90 Not below 150/90 Exceptions reported
35
Percentage of patients with a history of stroke whose last blood pressure reading
(measured in the preceding 12 months) is 150/90 mmHg or less by CCG
Comparison with CCGs in the STP
*Using the QOF clinical indicator STIA003
denominator plus exceptions
• 4,121 people with a history of stroke
or TIA* in NHS Ealing CCG
• 3,418 (82.9%) people whose blood
pressure is <= 150 / 90
• 214 (5.2%) people who are
exceptions
• 489 (11.9%) additional people whose
blood pressure is not <= 150 / 90
CVD: Primary Care Intelligence Packs
82.3%
82.8%
82.9%
82.9%
83.3%
83.6%
84.2%
84.6%
84.6%
84.8%
85.0%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Merton CCG
NHS Leicester City CCG
NHS Waltham Forest CCG
NHS Ealing CCG
NHS Hillingdon CCG
NHS Sandwell and West Birmingham CCG
NHS Brent CCG
NHS Hounslow CCG
NHS Redbridge CCG
NHS Harrow CCG
NHS Birmingham South and Central CCG
Below 150/90 Not below 150/90 Exceptions reported
36
Percentage of patients with a history of stroke whose last blood pressure reading
(measured in the preceding 12 months) is 150/90 mmHg or less by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
1
1
3
2
2
1
3
1
4
3
15
7
3
4
6
9
3
2
8
3
17
9
5
6
8
6
3
14
11
16
8
10
14
7
18
8
5
10
4
14
30
12
6
6
11
13
5
10
13
15
9
4
7
9
9
6
11
17
3
11
22
10
7
30
13
11
46
14
5
5
23
12
15
5
4
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
MATTOCK LANE HEALTH CENTRE E85726
THE TOWN SURGERY E85721
THE BURLINGTON GARDENS SURGERY E85705
ACTON LANE MEDICAL CENTRE E85687
WATERSIDE MEDICAL CENTRE E85006
RIBCHESTER MEDICAL CENTRE E85728
THE CUCKOO LANE PRACTICE E85116
CHISWICK FAMILY PRACTICE E85130
SUNRISE MEDICAL CENTRE E85656
BRUNSWICK ROAD MED.CTR. E85091
THE SALUJA CLINIC E85663
ALLENBY CLINIC E85105
HAMMOND ROAD SURGERY E85090
NORTHOLT FAMILY PRACTICE E85723
GORDON HOUSE SURGERY E85026
KS MEDICAL CENTRE E85012
ISLIP MANOR MEDICAL CENTRE E85098
THE MEDICAL CENTRE E85053
WEST END SURGERY E85064
EALING PARK HEALTH CENTRE E85657
THE CHURCHFIELD ROAD SURGERY E85640
THE HORN LANE SURGERY E85677
ELTHORNE PARK SURGERY E85628
ST.GEORGES MEDICAL CTR. E85743
QUEENS WALK PRACTICE E85057
CLOISTER ROAD SURGERY E85680
THE SOUTHALL MEDICAL CTR. E85633
DR SIVANESAN & PARTNER E85083
THE MILL HILL SURGERY E85107
THE ACTON HEALTH CENTRE E85109
HANWELL HEALTH CENTRE (STEWART) E85013
GREENFORD ROAD MED.CTR. E85050
NORTHFIELDS SURGERY E85014
CROWN STREET SURGERY E85019
MEDICAL CENTRE E85096
HILLCREST SURGERY E85028
GROSVENOR HOUSE SURGERY E85034
GOODCARE PRACTICE E85712
GURU NANAK MEDICAL CENTRE E85121
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
THE AVENUE SURGERY E85099
DORMERS WELLS MEDICAL CENTRE E85682
THE BEDFORD PARK SURGERY E85066
THE ARGYLE SURGERY E85120
THE FLORENCE ROAD SURGERY E85122
THE MANSELL ROAD PRACTICE E85129
BROADMEAD SURGERY E85715
LADY MARGARET ROAD MEDICAL CENTRE E85103
THE ALLENDALE ROAD SURGERY E84059
THE GROVE MEDICAL PRACTICE E85725
ACTON TOWN MEDICAL CENTRE E85617
MANDEVILLE MEDICAL CENTRE E85108
YEADING MEDICAL CENTRE E85021
GREENFORD AVENUE FHP E85051
HANWELL HEALTH CENTRE (NAISH) E85041
PERIVALE MEDICAL CLINIC E85111
ELMBANK SURGERY E85088
MEADOW VIEW E85643
OLDFIELD FAMILY PRACTICE E85069
WESTERN AVENUE SURGERY E85630
JUBILEE GARDENS MEDICAL CENTRE E85745
THE MWH PRACTICE E85119
THE NORTHCOTE MEDICAL CENTRE E85733
ELMTREES SURGERY E85112
THE BARNABAS MEDICAL CTRE E85127
THE VALE SURGERY E85635
WELCOME PRACTICE E85061
HILLVIEW SURGERY E85054
BELMONT MEDICAL CENTRE E85049
CHEPSTOW GARDENS MEDICAL CENTRE E85023
NURSING HOME SERVICES Y04225
THE PITSHANGER LANE SURGERY E85714
FEATHERSTONE ROAD HEALTH CENTRE Y02342
SOMERSET FHP O Y01221
EASTMEAD AVENUE SURGERY E85046
THE BOILEAU ROAD SURGERY E85694
THE CORFTON ROAD SURGERY E85123
THE LYNWOOD SURGERY E85740
SOMERSET MEDICAL CENTRE E85623
No treatment Exceptions reported
37
Percentage of patients with a history of stroke whose last blood pressure reading (measured
in the preceding 12 months) is not 150/90 mmHg or less by GP practice
• in total, including exceptions, there
are 703 people whose blood pressure
is not <= 150 / 90
• GP practice range: 0.0% to 36.4%
CVD: Primary Care Intelligence Packs
91.8%
87.3%
90.2%
90.3%
90.4%
90.8%
90.8%
91.8%
93.0%
0% 20% 40% 60% 80% 100%
England
NHS West London CCG
NHS Hammersmith And Fulham CCG
NHS Harrow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Central London (Westminster) CCG
NHS Hounslow CCG
NHS Ealing CCG
Below 150/90 Not below 150/90 Exceptions reported
38
Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA,
who have a record in the preceding 12 months that an anti-platelet agent, or an
anti-coagulant is being taken by CCG
Comparison with CCGs in the STP
*Using the QOF clinical indicator STIA007
denominator plus exceptions
CVD: Primary Care Intelligence Packs
• 2,444 people with a stroke shown to
be non-haemorrhagic* in NHS Ealing
CCG
• 2,272 (93%) people who are taking
an anti-platetet agent or anti-
coagulant
• 117 (4.8%) people who are
exceptions
• 55 (2.3%) additional people with no
treatment
90.2%
90.3%
90.4%
90.8%
90.9%
91.0%
91.3%
91.8%
92.5%
92.8%
93.0%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Leicester City CCG
NHS Harrow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Waltham Forest CCG
NHS Redbridge CCG
NHS Sandwell and West Birmingham CCG
NHS Hounslow CCG
NHS Birmingham South and Central CCG
NHS Merton CCG
NHS Ealing CCG
Below 150/90 Not below 150/90 Exceptions reported
39
Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA,
who have a record in the preceding 12 months that an anti-platelet agent,
or an anti-coagulant is being taken by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
3
1
1
1
2
2
1
1
3
1
2
3
1
1
1
2
2
2
3
1
2
2
2
5
3
3
3
2
1
1
6
1
4
1
6
4
1
7
7
13
9
2
2
3
3
2
14
5
3
9
6
6
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
SOMERSET FHP O Y01221
MATTOCK LANE HEALTH CENTRE E85726
NORTHOLT FAMILY PRACTICE E85723
THE TOWN SURGERY E85721
GOODCARE PRACTICE E85712
THE BURLINGTON GARDENS SURGERY E85705
ACTON LANE MEDICAL CENTRE E85687
THE SALUJA CLINIC E85663
SUNRISE MEDICAL CENTRE E85656
MEADOW VIEW E85643
THE CHURCHFIELD ROAD SURGERY E85640
THE SOUTHALL MEDICAL CTR. E85633
WESTERN AVENUE SURGERY E85630
SOMERSET MEDICAL CENTRE E85623
ALLENBY CLINIC E85105
THE AVENUE SURGERY E85099
BRUNSWICK ROAD MED.CTR. E85091
ELMBANK SURGERY E85088
DR SIVANESAN & PARTNER E85083
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
THE MEDICAL CENTRE E85053
BELMONT MEDICAL CENTRE E85049
HANWELL HEALTH CENTRE (NAISH) E85041
CHEPSTOW GARDENS MEDICAL CENTRE E85023
KS MEDICAL CENTRE E85012
WATERSIDE MEDICAL CENTRE E85006
THE ALLENDALE ROAD SURGERY E84059
GORDON HOUSE SURGERY E85026
WEST END SURGERY E85064
CLOISTER ROAD SURGERY E85680
ELMTREES SURGERY E85112
HILLVIEW SURGERY E85054
THE BARNABAS MEDICAL CTRE E85127
THE MANSELL ROAD PRACTICE E85129
JUBILEE GARDENS MEDICAL CENTRE E85745
QUEENS WALK PRACTICE E85057
MANDEVILLE MEDICAL CENTRE E85108
THE MWH PRACTICE E85119
NORTHFIELDS SURGERY E85014
LADY MARGARET ROAD MEDICAL CENTRE E85103
CHISWICK FAMILY PRACTICE E85130
YEADING MEDICAL CENTRE E85021
MEDICAL CENTRE E85096
THE CUCKOO LANE PRACTICE E85116
THE MILL HILL SURGERY E85107
EASTMEAD AVENUE SURGERY E85046
HANWELL HEALTH CENTRE (STEWART) E85013
THE VALE SURGERY E85635
DORMERS WELLS MEDICAL CENTRE E85682
BROADMEAD SURGERY E85715
CROWN STREET SURGERY E85019
GREENFORD AVENUE FHP E85051
ELTHORNE PARK SURGERY E85628
THE PITSHANGER LANE SURGERY E85714
THE ACTON HEALTH CENTRE E85109
ST.GEORGES MEDICAL CTR. E85743
THE LYNWOOD SURGERY E85740
GREENFORD ROAD MED.CTR. E85050
PERIVALE MEDICAL CLINIC E85111
HAMMOND ROAD SURGERY E85090
FEATHERSTONE ROAD HEALTH CENTRE Y02342
EALING PARK HEALTH CENTRE E85657
THE GROVE MEDICAL PRACTICE E85725
THE NORTHCOTE MEDICAL CENTRE E85733
GROSVENOR HOUSE SURGERY E85034
GURU NANAK MEDICAL CENTRE E85121
THE FLORENCE ROAD SURGERY E85122
THE ARGYLE SURGERY E85120
RIBCHESTER MEDICAL CENTRE E85728
ACTON TOWN MEDICAL CENTRE E85617
THE BEDFORD PARK SURGERY E85066
WELCOME PRACTICE E85061
THE HORN LANE SURGERY E85677
NURSING HOME SERVICES Y04225
THE BOILEAU ROAD SURGERY E85694
OLDFIELD FAMILY PRACTICE E85069
HILLCREST SURGERY E85028
THE CORFTON ROAD SURGERY E85123
ISLIP MANOR MEDICAL CENTRE E85098
No treatment Exceptions reported
40
Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA,
who do not have a record in the preceding 12 months that an anti-platelet agent,
or an anti-coagulant is being taken by GP practice
CVD: Primary Care Intelligence Packs
• in total, including exceptions, there
are 172 people who are not taking an
anti-platelet agent or anti-coagulant
• GP practice range: 0.0% to 31.6%
Diabetes
41 CVD: Primary Care Intelligence Packs
Type 2 Diabetes in numbers • diagnosed prevalence – 3.0 million
• undiagnosed diabetes – 900,000
• non-diabetic hyperglycaemia (high risk of diabetes) – 5 million
What might help • ensure universal participation by practices in the National
Diabetes Audit (NDA)
• benchmark practice level data from the NDA – and support
practices to explore variation
• increase support for patient education and shared
management
• maximise uptake of the NHS Health Check to aid detection of
diabetes and Non Diabetic Hyperglycaemia
• maximise uptake of the NHS Diabetes Prevention Programme
What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and
exception reporting?
2. how many people would benefit if all practices performed as well
as the best?
3. how can we support practices who are average and below
average to perform as well as the best in:
• detection of diabetes
• delivery of the 8 care processes and achievement of the 3
treatment targets
• identification and management of Non-diabetic hyperglycaemia
Type 2 diabetes is often preventable People at high risk of developing type 2 diabetes
can be identified through the NHS Health Check,
and the disease can be prevented or delayed in
many through intensive behaviour change support.
Complications of diabetes are preventable Diabetes is a major cause of premature death and
disability and greatly increases the risk of heart
disease and stroke, kidney failure, amputations and
blindness. 80% of NHS spending on diabetes goes
on managing these complications, most of which
could be prevented. There are 8 essential care
processes, in addition to retinal screening, that
together substantially reduce complication rates.
Despite this, around a half of people with diabetes
do not receive all 8 care processes, and there is
widespread variation between CCGs and practices
in levels of achievement
Diabetes prevention and management
42 CVD: Primary Care Intelligence Packs
Diabetes costs the NHS
£9.8 billion per year – and the
prevalence is rising
0.77
0.56
0.57
0.60
0.76
0.78
0.79
0.81
0.87
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
England
NHS West London CCG
NHS Central London (Westminster) CCG
NHS Hammersmith And Fulham CCG
NHS Ealing CCG
NHS Brent CCG
NHS Hounslow CCG
NHS Hillingdon CCG
NHS Harrow CCG
0.77
0.56
0.57
0.60
0.76
0.78
0.79
0.81
0.87
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
England
NHS West London CCG
NHS Central London (Westminster) CCG
NHS Hammersmith And Fulham CCG
NHS Ealing CCG
NHS Brent CCG
NHS Hounslow CCG
NHS Hillingdon CCG
NHS Harrow CCG
43
Diabetes observed prevalence compared with expected prevalence by CCG
Comparison with CCGs in the STP
CVD: Primary Care Intelligence Packs
Note: This slide compares the prevalence of
Diabetes recorded in QOF in 2015/16 to the
expected prevalence of Diabetes in 2016 taken
from the NCVIN diabetes prevalence model
produced in 2015.
• 0.76 ratio of observed to expected
diabetes prevalence in NHS Ealing
CCG, compared to 0.77 in England
• this suggests 76% of people have
been diagnosed
0.67
0.74
0.76
0.77
0.78
0.79
0.81
0.81
0.83
0.83
0.87
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
NHS Waltham Forest CCG
NHS Merton CCG
NHS Ealing CCG
NHS Redbridge CCG
NHS Brent CCG
NHS Hounslow CCG
NHS Sandwell and West Birmingham CCG
NHS Hillingdon CCG
NHS Leicester City CCG
NHS Birmingham South and Central CCG
NHS Harrow CCG
44
Diabetes observed prevalence compared with expected prevalence by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
2.8%
3.1%
3.6%
3.7%
4.0%
4.2%
4.2%
4.5%
4.6%
4.6%
4.6%
4.7%
4.8%
4.8%
4.9%
5.0%
5.0%
5.2%
5.4%
5.5%
5.7%
5.7%
5.7%
5.8%
5.8%
6.0%
6.0%
6.4%
6.4%
6.6%
6.7%
6.7%
6.8%
6.9%
7.0%
7.3%
7.3%
7.4%
7.4%
7.5%
7.6%
7.7%
7.9%
8.4%
8.4%
8.5%
8.7%
8.9%
8.9%
9.0%
9.0%
9.3%
9.5%
9.5%
9.8%
10.3%
10.3%
10.4%
10.5%
10.5%
10.9%
11.1%
11.2%
11.4%
11.4%
11.5%
11.8%
11.8%
11.9%
12.4%
12.6%
13.0%
13.9%
14.5%
14.7%
15.6%
16.3%
16.8%
24.3%
0% 5% 10% 15% 20% 25% 30%
THE BEDFORD PARK SURGERY E85066
THE CORFTON ROAD SURGERY E85123
THE FLORENCE ROAD SURGERY E85122
ACTON TOWN MEDICAL CENTRE E85617
CLOISTER ROAD SURGERY E85680
ACTON LANE MEDICAL CENTRE E85687
EALING PARK HEALTH CENTRE E85657
QUEENS WALK PRACTICE E85057
THE AVENUE SURGERY E85099
THE PITSHANGER LANE SURGERY E85714
THE HORN LANE SURGERY E85677
NORTHFIELDS SURGERY E85014
CHISWICK FAMILY PRACTICE E85130
THE ARGYLE SURGERY E85120
THE VALE SURGERY E85635
ELTHORNE PARK SURGERY E85628
HANWELL HEALTH CENTRE (STEWART) E85013
HILLCREST SURGERY E85028
GORDON HOUSE SURGERY E85026
THE ACTON HEALTH CENTRE E85109
HANWELL HEALTH CENTRE (NAISH) E85041
THE BOILEAU ROAD SURGERY E85694
THE CHURCHFIELD ROAD SURGERY E85640
THE MILL HILL SURGERY E85107
WESTERN AVENUE SURGERY E85630
BRUNSWICK ROAD MED.CTR. E85091
THE CUCKOO LANE PRACTICE E85116
PERIVALE MEDICAL CLINIC E85111
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
ISLIP MANOR MEDICAL CENTRE E85098
BROADMEAD SURGERY E85715
MATTOCK LANE HEALTH CENTRE E85726
THE GROVE MEDICAL PRACTICE E85725
CROWN STREET SURGERY E85019
THE LYNWOOD SURGERY E85740
THE BARNABAS MEDICAL CTRE E85127
GREENFORD AVENUE FHP E85051
WEST END SURGERY E85064
GREENFORD ROAD MED.CTR. E85050
OLDFIELD FAMILY PRACTICE E85069
FEATHERSTONE ROAD HEALTH CENTRE Y02342
MANDEVILLE MEDICAL CENTRE E85108
THE MEDICAL CENTRE E85053
THE MANSELL ROAD PRACTICE E85129
ELMTREES SURGERY E85112
EASTMEAD AVENUE SURGERY E85046
ALLENBY CLINIC E85105
GOODCARE PRACTICE E85712
THE BURLINGTON GARDENS SURGERY E85705
NORTHOLT FAMILY PRACTICE E85723
YEADING MEDICAL CENTRE E85021
THE ALLENDALE ROAD SURGERY E84059
GROSVENOR HOUSE SURGERY E85034
ELMBANK SURGERY E85088
HILLVIEW SURGERY E85054
MEDICAL CENTRE E85096
GURU NANAK MEDICAL CENTRE E85121
SOMERSET MEDICAL CENTRE E85623
ST.GEORGES MEDICAL CTR. E85743
DORMERS WELLS MEDICAL CENTRE E85682
THE SALUJA CLINIC E85663
THE SOUTHALL MEDICAL CTR. E85633
RIBCHESTER MEDICAL CENTRE E85728
BELMONT MEDICAL CENTRE E85049
WELCOME PRACTICE E85061
THE MWH PRACTICE E85119
JUBILEE GARDENS MEDICAL CENTRE E85745
WATERSIDE MEDICAL CENTRE E85006
HAMMOND ROAD SURGERY E85090
THE TOWN SURGERY E85721
MEADOW VIEW E85643
KS MEDICAL CENTRE E85012
CHEPSTOW GARDENS MEDICAL CENTRE E85023
THE NORTHCOTE MEDICAL CENTRE E85733
SOMERSET FHP O Y01221
SUNRISE MEDICAL CENTRE E85656
LADY MARGARET ROAD MEDICAL CENTRE E85103
DR SIVANESAN & PARTNER E85083
NURSING HOME SERVICES Y04225
GP practice CCG
45
Diabetes prevalence by GP practice
• GP practice range of observed
diabetes 2.8% to 24.3%
• there are an estimated 8,276 people
with undiagnosed diabetes in NHS
Ealing CCG
CVD: Primary Care Intelligence Packs
Note: The estimated number of undiagnosed
people with diabetes has been calculated by
multiplying the estimated prevalence rate to the
2015/16 QOF list size and subtracting the
number of people on the diabetes register.
6.5%
4.0%
4.5%
4.6%
7.0%
7.3%
7.8%
8.6%
9.1%
1.9%
3.1%
2.9%
3.7%
1.6%
1.9%
2.5%
2.5%
1.3%
11.2%
8.8%
8.7%
9.4%
11.6%
11.2%
11.9%
12.4%
13.6%
0% 5% 10% 15% 20% 25% 30%
England
NHS Central London (Westminster) CCG
NHS Hammersmith And Fulham CCG
NHS West London CCG
NHS Hillingdon CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Brent CCG
NHS Harrow CCG
Diabetes prevalence Undiagnosed diabetes prevalence
Expected non-diabetic hyperglycaemia prevalence
6.5%
4.0%
4.5%
4.6%
7.0%
7.3%
7.8%
8.6%
9.1%
1.9%
3.1%
2.9%
3.7%
1.6%
1.9%
2.5%
2.5%
1.3%
11.2%
8.8%
8.7%
9.4%
11.6%
11.2%
11.9%
12.4%
13.6%
0% 5% 10% 15% 20% 25% 30%
England
NHS Central London (Westminster) CCG
NHS Hammersmith And Fulham CCG
NHS West London CCG
NHS Hillingdon CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Brent CCG
NHS Harrow CCG
Diabetes prevalence Undiagnosed diabetes prevalence
Expected non-diabetic hyperglycaemia prevalence
46
Expected total prevalence of diabetes and non-diabetic hyperglycaemia
• the estimated total prevalence of
diabetes in NHS Ealing CCG is
10.2% (diagnosed and undiagnosed)
• in addition, there are an estimated
11.9% of people in NHS Ealing CCG
who are at increased risk of
developing diabetes (i.e. with non-
diabetic hyperglycaemia)
Note: Prevalence estimates of non-diabetic
hyperglycaemia were developed using Health
Survey for England (HSE) data. Five years of
HSE data were combined, 2009- 2013. The
estimates take into account the age, ethnic group
and estimated body mass index of the population.
These estimates were produced using the GP
registered population.
CVD: Primary Care Intelligence Packs
• this means that 22.1% of the
population in NHS Ealing CCG are
estimated to have diabetes, or at high
risk of developing of diabetes
52.6%
31.9%
36.8%
39.6%
47.1%
49.5%
50.5%
59.5%
62.1%
0% 10% 20% 30% 40% 50% 60% 70%
England
NHS Harrow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hounslow CCG
NHS Ealing CCG
52.6%
31.9%
36.8%
39.6%
47.1%
49.5%
50.5%
59.5%
62.1%
0% 10% 20% 30% 40% 50% 60% 70%
England
NHS Harrow CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hounslow CCG
NHS Ealing CCG
47
People with diabetes who had eight care processes by CCG 2015/16
• overall practice participation in the
2015/16 audit was 81.4% in England
• data on care processes and treatment
targets are taken from the National
Diabetes Audit (NDA)
• in NHS Ealing CCG, 69 out of 78
practices (88.5%) participated in the
NDA. Data is not available for the
remaining practices
CVD: Primary Care Intelligence Packs
• 62.1% of people with diabetes (of
practices who participated in the
audit) had the eight recommended
care processes in NHS Ealing CCG,
compared to 52.6% in England
14.2%
20.1%
31.3%
34.2%
35.3%
36.4%
43.9%
44.2%
45.1%
45.6%
47.2%
48.6%
49.3%
52.6%
53.0%
53.5%
55.3%
55.9%
56.0%
57.1%
57.1%
57.3%
58.1%
59.2%
59.8%
60.0%
60.2%
60.3%
60.7%
60.7%
62.0%
62.8%
62.9%
63.5%
64.2%
64.6%
64.9%
65.0%
65.6%
65.8%
66.1%
68.0%
68.5%
68.8%
69.4%
71.2%
71.3%
72.2%
72.4%
72.7%
72.8%
73.0%
74.0%
74.9%
75.2%
77.7%
78.1%
78.9%
81.8%
82.1%
82.6%
83.0%
83.3%
83.4%
83.9%
84.4%
86.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ISLIP MANOR MEDICAL CENTRE E85098
THE ARGYLE SURGERY E85120
ACTON TOWN MEDICAL CENTRE E85617
SUNRISE MEDICAL CENTRE E85656
THE HORN LANE SURGERY E85677
DORMERS WELLS MEDICAL CENTRE E85682
ACTON LANE MEDICAL CENTRE E85687
THE BURLINGTON GARDENS SURGERY E85705
GOODCARE PRACTICE E85712
MATTOCK LANE HEALTH CENTRE E85726
RIBCHESTER MEDICAL CENTRE E85728
NURSING HOME SERVICES Y04225
ALLENBY CLINIC E85105
NORTHOLT FAMILY PRACTICE E85723
THE BOILEAU ROAD SURGERY E85694
JUBILEE GARDENS MEDICAL CENTRE E85745
NORTHFIELDS SURGERY E85014
THE SOUTHALL MEDICAL CTR. E85633
BRUNSWICK ROAD MED.CTR. E85091
THE PITSHANGER LANE SURGERY E85714
WATERSIDE MEDICAL CENTRE E85006
THE GROVE MEDICAL PRACTICE E85725
QUEENS WALK PRACTICE E85057
YEADING MEDICAL CENTRE E85021
HANWELL HEALTH CENTRE (STEWART) E85013
WEST END SURGERY E85064
THE FLORENCE ROAD SURGERY E85122
GROSVENOR HOUSE SURGERY E85034
THE SALUJA CLINIC E85663
GREENFORD ROAD MED.CTR. E85050
HANWELL HEALTH CENTRE (NAISH) E85041
WELCOME PRACTICE E85061
PERIVALE MEDICAL CLINIC E85111
FEATHERSTONE ROAD HEALTH CENTRE Y02342
THE ALLENDALE ROAD SURGERY E84059
THE MWH PRACTICE E85119
HAMMOND ROAD SURGERY E85090
THE BEDFORD PARK SURGERY E85066
HILLVIEW SURGERY E85054
GREENFORD AVENUE FHP E85051
KS MEDICAL CENTRE E85012
MEADOW VIEW E85643
THE NORTHCOTE MEDICAL CENTRE E85733
MEDICAL CENTRE E85096
ELTHORNE PARK SURGERY E85628
EASTMEAD AVENUE SURGERY E85046
WESTERN AVENUE SURGERY E85630
LADY MARGARET ROAD MEDICAL CENTRE E85103
THE LYNWOOD SURGERY E85740
THE MANSELL ROAD PRACTICE E85129
MANDEVILLE MEDICAL CENTRE E85108
THE ACTON HEALTH CENTRE E85109
ST.GEORGES MEDICAL CTR. E85743
GURU NANAK MEDICAL CENTRE E85121
CHEPSTOW GARDENS MEDICAL CENTRE E85023
GORDON HOUSE SURGERY E85026
CROWN STREET SURGERY E85019
ELMTREES SURGERY E85112
BROADMEAD SURGERY E85715
BELMONT MEDICAL CENTRE E85049
THE MEDICAL CENTRE E85053
THE CUCKOO LANE PRACTICE E85116
SOMERSET MEDICAL CENTRE E85623
THE MILL HILL SURGERY E85107
HILLCREST SURGERY E85028
THE CORFTON ROAD SURGERY E85123
THE AVENUE SURGERY E85099
ELMBANK SURGERY E85088
THE VALE SURGERY E85635
EALING PARK HEALTH CENTRE E85657
CHISWICK FAMILY PRACTICE E85130
CLOISTER ROAD SURGERY E85680
SOMERSET FHP O Y01221
THE CHURCHFIELD ROAD SURGERY E85640
DR SIVANESAN & PARTNER E85083
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
THE BARNABAS MEDICAL CTRE E85127
OLDFIELD FAMILY PRACTICE E85069
THE TOWN SURGERY E85721
GP practice Average of practices in the CCG who participated in the audit
48
People with diabetes who had eight care processes by GP practice, 2015/16
CVD: Primary Care Intelligence Packs
• achievement - 8 care processes: in
practices who provided data via the
NDA, between 14.2% and 86.3% of
patients received all 8 care processes
• at least 8,702 people did not receive
the eight care processes
39.0%
37.0%
37.2%
38.6%
39.1%
39.1%
40.4%
42.2%
42.8%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
England
NHS Hammersmith And Fulham CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS West London CCG
NHS Brent CCG
NHS Harrow CCG
NHS Central London (Westminster) CCG
NHS Hillingdon CCG
39.0%
37.0%
37.2%
38.6%
39.1%
39.1%
40.4%
42.2%
42.8%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
England
NHS Hammersmith And Fulham CCG
NHS Ealing CCG
NHS Hounslow CCG
NHS West London CCG
NHS Brent CCG
NHS Harrow CCG
NHS Central London (Westminster) CCG
NHS Hillingdon CCG
49
People with diabetes who met all 3 treatment targets by CCG, 2015/16
CVD: Primary Care Intelligence Packs
• 37.2% of people with diabetes (of
practices who participated in the
audit) met the three treatment targets
in NHS Ealing CCG, compared to
39.0% in England
26.2%
26.6%
26.7%
26.7%
29.2%
29.4%
29.9%
30.6%
30.8%
30.9%
31.0%
31.7%
31.8%
32.0%
32.2%
32.3%
32.3%
32.6%
33.2%
33.2%
33.3%
33.4%
33.5%
33.8%
34.1%
34.1%
34.2%
34.6%
34.7%
34.8%
35.4%
35.9%
36.6%
36.9%
37.7%
38.0%
38.4%
38.4%
39.1%
39.2%
39.6%
39.6%
40.0%
40.2%
40.2%
41.1%
43.1%
43.2%
43.7%
43.8%
43.9%
44.1%
44.6%
45.2%
45.4%
45.5%
46.2%
46.3%
46.8%
46.8%
47.8%
48.9%
49.7%
55.1%
55.3%
61.8%
63.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ISLIP MANOR MEDICAL CENTRE E85098
THE ARGYLE SURGERY E85120
ACTON TOWN MEDICAL CENTRE E85617
SUNRISE MEDICAL CENTRE E85656
THE HORN LANE SURGERY E85677
DORMERS WELLS MEDICAL CENTRE E85682
ACTON LANE MEDICAL CENTRE E85687
THE BURLINGTON GARDENS SURGERY E85705
GOODCARE PRACTICE E85712
MATTOCK LANE HEALTH CENTRE E85726
RIBCHESTER MEDICAL CENTRE E85728
NURSING HOME SERVICES Y04225
BRUNSWICK ROAD MED.CTR. E85091
BROADMEAD SURGERY E85715
FEATHERSTONE ROAD HEALTH CENTRE Y02342
EASTMEAD AVENUE SURGERY E85046
LADY MARGARET ROAD MEDICAL CENTRE E85103
HILLVIEW SURGERY E85054
THE PITSHANGER LANE SURGERY E85714
THE ACTON HEALTH CENTRE E85109
THE CORFTON ROAD SURGERY E85123
JUBILEE GARDENS MEDICAL CENTRE E85745
THE MWH PRACTICE E85119
THE NORTHCOTE MEDICAL CENTRE E85733
WELCOME PRACTICE E85061
SOMERSET MEDICAL CENTRE E85623
GURU NANAK MEDICAL CENTRE E85121
SOMERSET FHP O Y01221
GREENFORD ROAD MED.CTR. E85050
THE LYNWOOD SURGERY E85740
THE SOUTHALL MEDICAL CTR. E85633
ELTHORNE PARK SURGERY E85628
YEADING MEDICAL CENTRE E85021
BELMONT MEDICAL CENTRE E85049
THE FLORENCE ROAD SURGERY E85122
THE MILL HILL SURGERY E85107
MEDICAL CENTRE E85096
HANWELL HEALTH CENTRE (STEWART) E85013
THE ALLENDALE ROAD SURGERY E84059
CLOISTER ROAD SURGERY E85680
THE VALE SURGERY E85635
MANDEVILLE MEDICAL CENTRE E85108
EALING PARK HEALTH CENTRE E85657
DR SIVANESAN & PARTNER E85083
KS MEDICAL CENTRE E85012
HANWELL HEALTH CENTRE (NAISH) E85041
WATERSIDE MEDICAL CENTRE E85006
THE BOILEAU ROAD SURGERY E85694
THE SALUJA CLINIC E85663
CROWN STREET SURGERY E85019
HILLCREST SURGERY E85028
ST.GEORGES MEDICAL CTR. E85743
HAMMOND ROAD SURGERY E85090
NORTHFIELDS SURGERY E85014
THE CUCKOO LANE PRACTICE E85116
CHEPSTOW GARDENS MEDICAL CENTRE E85023
MEADOW VIEW E85643
GREENFORD AVENUE FHP E85051
NORTHOLT FAMILY PRACTICE E85723
ALLENBY CLINIC E85105
GROSVENOR HOUSE SURGERY E85034
GORDON HOUSE SURGERY E85026
THE BARNABAS MEDICAL CTRE E85127
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
THE MANSELL ROAD PRACTICE E85129
THE GROVE MEDICAL PRACTICE E85725
THE AVENUE SURGERY E85099
WEST END SURGERY E85064
PERIVALE MEDICAL CLINIC E85111
WESTERN AVENUE SURGERY E85630
THE BEDFORD PARK SURGERY E85066
THE MEDICAL CENTRE E85053
ELMTREES SURGERY E85112
OLDFIELD FAMILY PRACTICE E85069
THE CHURCHFIELD ROAD SURGERY E85640
CHISWICK FAMILY PRACTICE E85130
ELMBANK SURGERY E85088
THE TOWN SURGERY E85721
QUEENS WALK PRACTICE E85057
GP practice Average of practices in the CCG who participated in the audit
50
People with diabetes who met all 3 treatment targets by GP practice, 2015/16
CVD: Primary Care Intelligence Packs
• achievement - 3 treatment targets: in
practices who provided data via the
NDA, between 26.2% and 63.3% of
patients achieved all 3 treatment
targets
• at least 12,654 people did not meet
the three treatment targets
12
65
58
29
58
14
94
21
80
23
-25%-20%-15%-10%-5%0%5%10%15%20%25%
BRUNSWICK ROAD MED.CTR.
FEATHERSTONE ROAD HEALTH CENTRE
EASTMEAD AVENUE SURGERY
BROADMEAD SURGERY
LADY MARGARET ROAD MEDICAL CENTRE
THE PITSHANGER LANE SURGERY
HILLVIEW SURGERY
THE CORFTON ROAD SURGERY
THE MWH PRACTICE
THE NORTHCOTE MEDICAL CENTRE
WEST END SURGERY
PERIVALE MEDICAL CLINIC
THE MEDICAL CENTRE
ELMTREES SURGERY
THE CHURCHFIELD ROAD SURGERY
OLDFIELD FAMILY PRACTICE
CHISWICK FAMILY PRACTICE
ELMBANK SURGERY
THE TOWN SURGERY
QUEENS WALK PRACTICE
51
People with diabetes who met all 3 treatment targets by GP practice, 2015/16
- opportunities compared to GP cluster
CVD: Primary Care Intelligence Packs
• using the GP cluster method of
calculating potential gains, if each
practice was to achieve as well as the
upper quartile of its national cluster,
then an additional 1,568 people would
be treated
Details of this methodology are available on slide
9. Click here to view them.
Kidney
52 CVD: Primary Care Intelligence Packs
Chronic Kidney Disease can
progress to kidney failure and it
substantially increases the risk
of heart attack and stroke.
Chronic Kidney Disease (CKD) is common.
It is one of the commonest co-morbidities and affects a third
of people over 75. In 2010 it was estimated to cost the NHS
around £1.5bn. Average length of stay in hospital tends to
be longer and outcomes are considerably worse:
approximately 7,000 excess strokes and 12,000 excess
heart attacks occur each year in people with CKD
compared to those without.
Individuals with CKD are also at much higher risk of
developing acute kidney injury when they have an
intercurrent illness such as pneumonia What might help • Support practices to share audit data and systematically
identify gaps and opportunities for improved detection
and management of CKD.
• Promote uptake of and follow up from the NHS Health
Check to aid detection and management of CKD
• Offer local training and education in the detection and
management of CKD
What questions should we ask in our CCG? 1. for each indicator how wide is the variation in
achievement and exception reporting?
2. how many people would benefit if all practices
performed as well as the best?
3. how can we support practices who are average and
below average to perform as well as the best in:
• detection of CKD
• more systematic delivery of evidence based care
Late diagnosis of CKD is common. Around a third of people with CKD are undiagnosed. More
opportunistic testing and improved uptake of the NHS
Health Check will increase detection rates.
Evidence based guidance from NICE highlights CVD
risk reduction, good blood pressure control and
management of proteinuria as essential steps to reduce the
risk of cardiovascular events and progression to kidney
failure. Despite this there is often significant variation
between practices in achievement and exception reporting.
Management of chronic kidney disease
53 CVD: Primary Care Intelligence Packs
0.68
0.33
0.40
0.41
0.43
0.49
0.50
0.55
0.56
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
England
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Harrow CCG
NHS Ealing CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Hammersmith And Fulham CCG
NHS Hounslow CCG
Ratio
0.68
0.33
0.40
0.41
0.43
0.49
0.50
0.55
0.56
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
England
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Harrow CCG
NHS Ealing CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Hammersmith And Fulham CCG
NHS Hounslow CCG
Ratio
54
Chronic kidney disease (CKD) observed prevalence (2015/16) compared
with expected prevalence (2011) by CCG
Comparison with CCGs in the STP
Note: This slide compares the prevalence of CKD
recorded in QOF in 2015/16 to the expected
prevalence of CKD produced by the University of
Southampton in 2011. A small number of CCGs
have a ratio greater than 1. It is unlikely that all
people with CKD will be diagnosed in any CCG
and therefore a ratio greater than 1 suggests that
the figures are underestimating the true CKD
prevalence in the area. These ratios should be
taken as an indication of the comparative scale of
undiagnosed CKD rather than absolute figures.
• the ratio of those diagnosed with
chronic kidney disease versus those
expected to have chronic kidney
disease is 0.43. This compares to
0.68 for England
• this suggests that 43% of people with
chronic kidney disease have been
diagnosed
CVD: Primary Care Intelligence Packs
0.41
0.43
0.49
0.50
0.50
0.52
0.52
0.56
0.60
0.69
0.76
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
NHS Harrow CCG
NHS Ealing CCG
NHS Brent CCG
NHS Hillingdon CCG
NHS Redbridge CCG
NHS Leicester City CCG
NHS Waltham Forest CCG
NHS Hounslow CCG
NHS Merton CCG
NHS Sandwell and West Birmingham CCG
NHS Birmingham South and Central CCG
Ratio
55
Chronic kidney disease (CKD) observed prevalence (2015/16)
compared with expected prevalence (2011) by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
0.4%
0.6%
0.6%
0.6%
0.6%
0.7%
0.7%
0.8%
0.9%
0.9%
1.0%
1.0%
1.0%
1.1%
1.1%
1.1%
1.3%
1.3%
1.3%
1.4%
1.4%
1.5%
1.5%
1.6%
1.6%
1.6%
1.6%
1.6%
1.6%
1.7%
1.7%
1.7%
1.7%
1.8%
1.8%
1.9%
1.9%
1.9%
1.9%
2.0%
2.0%
2.1%
2.1%
2.1%
2.1%
2.2%
2.2%
2.2%
2.2%
2.2%
2.2%
2.3%
2.3%
2.4%
2.4%
2.4%
2.4%
2.5%
2.6%
2.6%
2.6%
2.6%
2.6%
2.7%
2.9%
2.9%
2.9%
3.0%
3.1%
3.2%
3.2%
3.4%
3.4%
3.5%
3.6%
4.1%
4.7%
5.0%
18.4%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%
THE BARNABAS MEDICAL CTRE E85127
LADY MARGARET ROAD MEDICAL CENTRE E85103
FEATHERSTONE ROAD HEALTH CENTRE Y02342
BRUNSWICK ROAD MED.CTR. E85091
THE SOUTHALL MEDICAL CTR. E85633
THE TOWN SURGERY E85721
MEDICAL CENTRE E85096
ACTON LANE MEDICAL CENTRE E85687
THE LYNWOOD SURGERY E85740
SUNRISE MEDICAL CENTRE E85656
THE HORN LANE SURGERY E85677
WATERSIDE MEDICAL CENTRE E85006
GURU NANAK MEDICAL CENTRE E85121
THE SALUJA CLINIC E85663
THE VALE SURGERY E85635
SOMERSET FHP O Y01221
THE MILL HILL SURGERY E85107
ALLENBY CLINIC E85105
HANWELL HEALTH CENTRE (NAISH) E85041
THE BEDFORD PARK SURGERY E85066
ACTON TOWN MEDICAL CENTRE E85617
THE CORFTON ROAD SURGERY E85123
JUBILEE GARDENS MEDICAL CENTRE E85745
THE FLORENCE ROAD SURGERY E85122
BROADMEAD SURGERY E85715
BELMONT MEDICAL CENTRE E85049
ST.GEORGES MEDICAL CTR. E85743
NORTHOLT FAMILY PRACTICE E85723
EALING PARK HEALTH CENTRE E85657
ISLIP MANOR MEDICAL CENTRE E85098
ELMTREES SURGERY E85112
PERIVALE MEDICAL CLINIC E85111
CLOISTER ROAD SURGERY E85680
ELTHORNE PARK SURGERY E85628
GROSVENOR HOUSE SURGERY E85034
DORMERS WELLS MEDICAL CENTRE E85682
OLDFIELD FAMILY PRACTICE E85069
MANDEVILLE MEDICAL CENTRE E85108
ELMBANK SURGERY E85088
SOMERSET MEDICAL CENTRE E85623
THE CHURCHFIELD ROAD SURGERY E85640
GOODCARE PRACTICE E85712
THE NORTHCOTE MEDICAL CENTRE E85733
YEADING MEDICAL CENTRE E85021
THE BOILEAU ROAD SURGERY E85694
THE MANSELL ROAD PRACTICE E85129
THE AVENUE SURGERY E85099
THE MWH PRACTICE E85119
GREENFORD AVENUE FHP E85051
THE GROVE MEDICAL PRACTICE E85725
HILLCREST SURGERY E85028
MATTOCK LANE HEALTH CENTRE E85726
THE CUCKOO LANE PRACTICE E85116
THE MEDICAL CENTRE E85053
WESTERN AVENUE SURGERY E85630
THE BURLINGTON GARDENS SURGERY E85705
THE ALLENDALE ROAD SURGERY E84059
HAMMOND ROAD SURGERY E85090
GREENFORD ROAD MED.CTR. E85050
WELCOME PRACTICE E85061
THE ACTON HEALTH CENTRE E85109
NORTHFIELDS SURGERY E85014
EASTMEAD AVENUE SURGERY E85046
KS MEDICAL CENTRE E85012
CROWN STREET SURGERY E85019
HILLVIEW SURGERY E85054
HANWELL HEALTH CENTRE (STEWART) E85013
THE ARGYLE SURGERY E85120
GORDON HOUSE SURGERY E85026
THE PITSHANGER LANE SURGERY E85714
CHISWICK FAMILY PRACTICE E85130
MEADOW VIEW E85643
RIBCHESTER MEDICAL CENTRE E85728
DR SIVANESAN & PARTNER E85083
WEST END SURGERY E85064
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
QUEENS WALK PRACTICE E85057
CHEPSTOW GARDENS MEDICAL CENTRE E85023
NURSING HOME SERVICES Y04225
GP practice CCG
56
CKD prevalence by GP practice, 2015/16
Note: CCG estimates for the estimated
number of people with CKD are based on
applying a proportion from a resident based
population estimate to a GP registered
population. The characteristics of registered
and resident populations may vary in some
CCGs, and local interpretation is required.
• it is estimated that there are 8,974
people with undiagnosed chronic
kidney disease in NHS Ealing CCG
• GP practice range of observed CKD:
0.4% to 18.4%
CVD: Primary Care Intelligence Packs
74.4%
70.3%
73.3%
73.3%
74.9%
75.1%
75.3%
75.7%
77.1%
0% 20% 40% 60% 80% 100%
England
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hounslow CCG
NHS Harrow CCG
NHS Brent CCG
NHS Ealing CCG
NHS Hillingdon CCG
Below 140/85 Not below 140/85 Exceptions reported
57
Percentage of patients on the CKD register whose last blood pressure reading (measured in
the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15
Comparison with CCGs in the STP
*Using the QOF clinical indicator CKD002
denominator plus exceptions. Note: as
the CKD002 indicator was removed from
the QOF in 15/16 this is historic data
taken from the 2014/15 QOF.
• 6,931 people with CKD (diagnosed*)
in NHS Ealing CCG
• 5,245 (75.7%) people whose blood
pressure is <= 140 /85
• 576 (8.3%) people who are
exceptions
• 1,110 (16%) additional people whose
blood pressure is not <= 140 / 85
CVD: Primary Care Intelligence Packs
74.5%
74.8%
74.9%
75.1%
75.3%
75.5%
75.7%
75.7%
75.8%
77.1%
78.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Sandwell and West Birmingham CCG
NHS Leicester City CCG
NHS Hounslow CCG
NHS Harrow CCG
NHS Brent CCG
NHS Birmingham South and Central CCG
NHS Redbridge CCG
NHS Ealing CCG
NHS Waltham Forest CCG
NHS Hillingdon CCG
NHS Merton CCG
Below 140/85 Not below 140/85 Exceptions reported
58
Percentage of patients on the CKD register whose last blood pressure reading (measured
in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
1
1
3
3
1
5
5
9
7
6
3
6
9
13
13
9
17
5
14
17
37
17
15
24
24
9
79
12
23
30
12
28
26
16
19
24
15
51
79
16
31
22
6
20
48
50
1
34
2
17
17
32
29
16
10
23
40
22
11
39
40
27
7
30
21
33
13
39
12
27
16
31
40
21
119
13
16
8
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
DR SM YIN E85687
DR NN PATEL E85728
DR MA KHAN E85677
BROADMEAD SURGERY E85715
DR JS SANGHERA E85633
DR S RADHAKRISHNAN E85721
DR CSP REDDY E85635
DR N KOYE E85111
DR BP SINHA E85630
DR JM BAYER E85099
DR BS MANGAT E85096
ALLENBY CLINIC E85105
DR A BOTROS E85743
DR KK GYI E85726
DR RC STEWART E85013
DR RJ SALUJA E85663
CHURCHFIELD SURGERY DRS SN & SSJ DATTA E85640
DR DA JENKINS E85129
WATERSIDE HEALTH CENTRE E85006
MANDEVILLE MEDICAL CENTRE E85108
DR HM QADAN E85682
DR DS COWEN E85014
DR R DASOJU E85034
DR G BALACHANDRAN E85053
DR RK BHATT E85725
WEST END SURGERY E85064
DR WM MOUSTAFA E85617
DR N CROWLEY E85057
DR L DAS E85694
DR VB BHATT E85130
DR AM WEBER E85075
ELMBANK SURGERY E85088
CLOISTER ROAD SURGERY E85680
DR PJS SANDHU E85090
GOODCARE PRACTICE E85712
CUCKOO LANE HEALTH CARE LTD E85116
DR MG MIKHAIL E85023
DRS BASSI & KAMBOJ E85041
DR DCM EVANS & PARTNERS E85122
GORDON HOUSE SURGERY E85026
DR N ISSAC E85109
DR SIVANESAN & PARTNER E85083
GREENFORD AVENUE FHP E85051
DR MG PARMAR E85127
CORFTON ROAD SURGERY E85123
CROWN STREET SURGERY E85019
THE ARGYLE SURGERY E85120
DR AL-HASANI E85740
EALING PARK HEALTH CENTRE E85657
DR NF LEWIS E85091
DR SO ALI E85723
ELM TREES SURGERY E85112
DR G SIVARAJAH E85643
DR R SHAH E85628
DR B GOHIL E85069
DR SA QURESHI E85623
KS MEDICAL CENTRE LTD E85012
HILLCREST SURGERY E85028
DR AK SANDHU E85049
DR OS SAHOTA E85731
DR RC MOORE E85050
MWH PRACTICE E85119
DR PERINPANAYAGAM & PARTNERS E85021
SUNRISE MEDICAL CENTRE E85656
JUBILEE GARDENS MEDICAL CENTRE E85745
DR N ASGHAR E85061
THE GURU NANAK MEDICAL CENTRE E85121
FEATHERSTONE ROAD HEALTH CENTRE Y02342
DR SK GILL E85046
DR HM MAMDANI E85705
DR K CABOT E85107
DR JW KEEN E85066
DR SHC VALENTINE E85714
DR SS GORAYA E84059
ISLIP MANOR MEDICAL CENTRE E85098
DR SS SHERGILL E85054
SOMERSET FAMILY HEALTH Y01221
THE NORTHCOTE MEDICAL CENTRE E85733
LADY MARAGRET ROAD MEDICAL CENTRE E85103
Not below 140/85 Exceptions reported
59
Percentage of patients on the CKD register whose last blood pressure reading (measured in
the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15
• in total, including exceptions, there
are 1,686 people whose blood
pressure is not <= 140 / 85
• GP practice range: 0.0% to 57.1%
CVD: Primary Care Intelligence Packs
6
11
9
79
13
25
18
9
15
7
-50%-40%-30%-20%-10%0%10%20%
LADY MARAGRET ROAD MEDICAL CENTRE
THE NORTHCOTE MEDICAL CENTRE
SOMERSET FAMILY HEALTH
DR SS SHERGILL
ISLIP MANOR MEDICAL CENTRE
DR SS GORAYA
DR SHC VALENTINE
DR JW KEEN
DR K CABOT
DR HM MAMDANI
DR JM BAYER
DR BP SINHA
DR N KOYE
DR CSP REDDY
DR S RADHAKRISHNAN
DR JS SANGHERA
BROADMEAD SURGERY
DR MA KHAN
DR NN PATEL
DR SM YIN
60
Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding
12 months) is not 140/85 mmHg or less by GP practice, 2014/15 – opportunities compared to GP cluster
• using the GP cluster method of
calculating potential gains, if each
practice was to achieve as well as the
upper quartile of its national cluster,
then an additional 543 people would
be treated
CVD: Primary Care Intelligence Packs
Details of this methodology are available on slide
9. Click here to view them.
75.4%
69.6%
73.5%
73.5%
74.1%
74.4%
75.5%
76.0%
78.6%
0% 20% 40% 60% 80% 100%
England
NHS Hammersmith And Fulham CCG
NHS West London CCG
NHS Central London (Westminster) CCG
NHS Hounslow CCG
NHS Brent CCG
NHS Ealing CCG
NHS Harrow CCG
NHS Hillingdon CCG
Recorded Not recorded Exceptions reported
61
Percentage of patients on the CKD register whose notes have a record of a
urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15
Comparison with CCGs in the STP
• 6,931 people with CKD (diagnosed*)
in NHS Ealing CCG
• 5,236 (75.5%) people who have a
record of urine albumin:creatinine
ratio test
• 407 (5.9%) people who are
exceptions
• 1,288 (18.6%) additional people who
have no record of urine
albumin:creatinine ratio test
*Using the QOF clinical indicator CKD004
denominator plus exceptions. Note: as
the CKD004 indicator was removed from
the QOF in 15/16 this is historic data
taken from the 2014/15 QOF.
CVD: Primary Care Intelligence Packs
61.6%
74.1%
74.4%
74.4%
74.7%
74.9%
75.5%
76.0%
76.8%
77.0%
78.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Redbridge CCG
NHS Hounslow CCG
NHS Merton CCG
NHS Brent CCG
NHS Waltham Forest CCG
NHS Leicester City CCG
NHS Ealing CCG
NHS Harrow CCG
NHS Sandwell and West Birmingham CCG
NHS Birmingham South and Central CCG
NHS Hillingdon CCG
Recorded Not recorded Exceptions reported
62
Percentage of patients on the CKD register whose notes have a record of a
urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
1
2
2
5
3
1
4
5
5
7
6
6
4
17
11
8
11
12
15
11
10
8
13
19
6
6
33
11
14
10
16
34
24
7
25
22
43
29
19
12
24
76
29
23
10
28
15
29
17
25
21
81
48
19
26
24
34
19
33
15
26
8
30
32
16
39
51
43
39
122
14
4
8
83
5
44
35
3
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
DR MA KHAN E85677
ALLENBY CLINIC E85105
SOMERSET FAMILY HEALTH Y01221
DR MG PARMAR E85127
ELMBANK SURGERY E85088
DR HM MAMDANI E85705
DR S RADHAKRISHNAN E85721
DR JS SANGHERA E85633
BROADMEAD SURGERY E85715
DR A BOTROS E85743
CHURCHFIELD SURGERY DRS SN & SSJ DATTA E85640
DR N KOYE E85111
DR BS MANGAT E85096
WATERSIDE HEALTH CENTRE E85006
DR RK BHATT E85725
DR G BALACHANDRAN E85053
DR JM BAYER E85099
DR BP SINHA E85630
DR RJ SALUJA E85663
DR DA JENKINS E85129
GOODCARE PRACTICE E85712
DR SO ALI E85723
DR NN PATEL E85728
CUCKOO LANE HEALTH CARE LTD E85116
DR PJS SANDHU E85090
FEATHERSTONE ROAD HEALTH CENTRE Y02342
DR OS SAHOTA E85731
DR DS COWEN E85014
ELM TREES SURGERY E85112
DR RC STEWART E85013
DR KK GYI E85726
GREENFORD AVENUE FHP E85051
CROWN STREET SURGERY E85019
EALING PARK HEALTH CENTRE E85657
DR SA QURESHI E85623
CLOISTER ROAD SURGERY E85680
DR SK GILL E85046
DR DCM EVANS & PARTNERS E85122
HILLCREST SURGERY E85028
THE GURU NANAK MEDICAL CENTRE E85121
DR B GOHIL E85069
WEST END SURGERY E85064
DR N CROWLEY E85057
DR AM WEBER E85075
DR R SHAH E85628
DR CSP REDDY E85635
MWH PRACTICE E85119
DR N ISSAC E85109
DR SIVANESAN & PARTNER E85083
DR K CABOT E85107
DR VB BHATT E85130
DR R DASOJU E85034
GORDON HOUSE SURGERY E85026
THE ARGYLE SURGERY E85120
DRS BASSI & KAMBOJ E85041
DR PERINPANAYAGAM & PARTNERS E85021
DR AK SANDHU E85049
DR MG MIKHAIL E85023
DR L DAS E85694
DR HM QADAN E85682
DR WM MOUSTAFA E85617
DR SHC VALENTINE E85714
SUNRISE MEDICAL CENTRE E85656
CORFTON ROAD SURGERY E85123
KS MEDICAL CENTRE LTD E85012
DR JW KEEN E85066
DR SS GORAYA E84059
DR G SIVARAJAH E85643
JUBILEE GARDENS MEDICAL CENTRE E85745
MANDEVILLE MEDICAL CENTRE E85108
DR SS SHERGILL E85054
THE NORTHCOTE MEDICAL CENTRE E85733
DR SM YIN E85687
LADY MARAGRET ROAD MEDICAL CENTRE E85103
DR RC MOORE E85050
DR NF LEWIS E85091
DR N ASGHAR E85061
ISLIP MANOR MEDICAL CENTRE E85098
DR AL-HASANI E85740
Not recorded Exceptions reported
63
Percentage of patients on the CKD register whose notes do not have a record of a
urine albumin: creatinine ratio test in the preceding 12 months by GP practice, 2014/15
• in total, including exceptions, there
are 1,695 people who have no record
of urine albumin:creatinine ratio test
• GP practice range: 0.0% to 75.0%
CVD: Primary Care Intelligence Packs
Heart
64 CVD: Primary Care Intelligence Packs
Coronary Heart Disease is one of the principal causes of
premature death and disability. The key elements of management for
an individual who has already had a heart attack or angina are
symptom control and secondary prevention of further cardiovascular
events and premature mortality. There is robust evidence to support the
use of anti-platelet treatment, statins, beta-blockers and angiotensin
converting enzyme inhibitors or angiotensin receptor blockers. There is
also robust evidence to support good control of blood pressure. Each of
these interventions is incentivised in QOF but variation in achievement
and exception reporting at practice level shows that there is often
considerable potential for improving management and outcomes.
What might help 1. roll out of GRASP-Heart Failure audit tool
that identifies people with heart failure who
are undiagnosed or under treated
2. education for health professionals to
promote evidence based management of
CHD and high quality measurement of
blood pressure
3. ensure access to rapid access diagnostic
clinics and specialist support for
management of angina and heart failure
4. ensure access to cardiac rehab for
individuals with CHD and heart failure
What questions should we ask in our CCG? 1. for each indicator how wide is the variation in
achievement and exception reporting?
2. how many people would benefit if all
practices performed as well as the best?
3. how can we support practices who are
average and below average to perform as
well as the best in:
• more systematic delivery of evidence
based care for people with CHD
• improved detection and management
of heart failure
Heart failure is a common and an important complication of
coronary heart disease and other conditions. Appropriate treatment
including up-titration of ace inhibitors and beta blockers in heart failure
due to LVSD can significantly improve symptom control and quality of
life, and improve outcomes for patients. Despite this, around a quarter
of people with heart failure are undetected and untreated. And amongst
those who are diagnosed, there is significant variation in the quality of
care.
Management of Heart Disease
65 CVD: Primary Care Intelligence Packs
Premature death and disability in people with
CHD can be reduced significantly by systematic
evidence based management in primary care
0.76%
0.40%
0.41%
0.44%
0.46%
0.49%
0.51%
0.54%
0.57%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8%
England
NHS West London CCG
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS Ealing CCG
NHS Hillingdon CCG
NHS Hounslow CCG
NHS Brent CCG
NHS Harrow CCG
0.76%
0.40%
0.41%
0.44%
0.46%
0.49%
0.51%
0.54%
0.57%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8%
England
NHS West London CCG
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS Ealing CCG
NHS Hillingdon CCG
NHS Hounslow CCG
NHS Brent CCG
NHS Harrow CCG
66
Heart failure prevalence by CCG
Comparison with CCGs in the STP
• prevalence of 0.46% in NHS Ealing
CCG compared to 0.76% in England
CVD: Primary Care Intelligence Packs
0.45%
0.46%
0.46%
0.48%
0.49%
0.51%
0.54%
0.57%
0.60%
0.68%
0.68%
0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6% 0.7% 0.8%
NHS Redbridge CCG
NHS Ealing CCG
NHS Waltham Forest CCG
NHS Merton CCG
NHS Hillingdon CCG
NHS Hounslow CCG
NHS Brent CCG
NHS Harrow CCG
NHS Birmingham South and Central CCG
NHS Leicester City CCG
NHS Sandwell and West Birmingham CCG
67
Heart failure prevalence by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
0.1%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.3%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.4%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.5%
0.6%
0.6%
0.6%
0.6%
0.6%
0.6%
0.6%
0.6%
0.6%
0.6%
0.7%
0.7%
0.7%
0.7%
0.7%
0.7%
0.8%
0.8%
0.8%
1.1%
7.6%
0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0%
THE TOWN SURGERY E85721
MEDICAL CENTRE E85096
SOMERSET FHP O Y01221
FEATHERSTONE ROAD HEALTH CENTRE Y02342
HANWELL HEALTH CENTRE (NAISH) E85041
THE VALE SURGERY E85635
PERIVALE MEDICAL CLINIC E85111
THE MANSELL ROAD PRACTICE E85129
BRUNSWICK ROAD MED.CTR. E85091
MEADOW VIEW E85643
WATERSIDE MEDICAL CENTRE E85006
ACTON LANE MEDICAL CENTRE E85687
ELMTREES SURGERY E85112
CLOISTER ROAD SURGERY E85680
THE LYNWOOD SURGERY E85740
THE HORN LANE SURGERY E85677
WESTERN AVENUE SURGERY E85630
RIBCHESTER MEDICAL CENTRE E85728
SOMERSET MEDICAL CENTRE E85623
HILLCREST SURGERY E85028
CHISWICK FAMILY PRACTICE E85130
NORTHOLT FAMILY PRACTICE E85723
THE SOUTHALL MEDICAL CTR. E85633
MANDEVILLE MEDICAL CENTRE E85108
GOODCARE PRACTICE E85712
NORTHFIELDS SURGERY E85014
THE ACTON HEALTH CENTRE E85109
ISLIP MANOR MEDICAL CENTRE E85098
THE SALUJA CLINIC E85663
THE CORFTON ROAD SURGERY E85123
THE CHURCHFIELD ROAD SURGERY E85640
HANWELL HEALTH CENTRE (STEWART) E85013
THE BURLINGTON GARDENS SURGERY E85705
THE GROVE MEDICAL PRACTICE E85725
THE MILL HILL SURGERY E85107
THE BOILEAU ROAD SURGERY E85694
THE BEDFORD PARK SURGERY E85066
WELCOME PRACTICE E85061
MATTOCK LANE HEALTH CENTRE E85726
EASTMEAD AVENUE SURGERY E85046
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
THE FLORENCE ROAD SURGERY E85122
EALING PARK HEALTH CENTRE E85657
THE ARGYLE SURGERY E85120
GREENFORD AVENUE FHP E85051
BELMONT MEDICAL CENTRE E85049
DORMERS WELLS MEDICAL CENTRE E85682
JUBILEE GARDENS MEDICAL CENTRE E85745
CROWN STREET SURGERY E85019
THE ALLENDALE ROAD SURGERY E84059
OLDFIELD FAMILY PRACTICE E85069
THE BARNABAS MEDICAL CTRE E85127
THE MEDICAL CENTRE E85053
GREENFORD ROAD MED.CTR. E85050
ST.GEORGES MEDICAL CTR. E85743
YEADING MEDICAL CENTRE E85021
GORDON HOUSE SURGERY E85026
ACTON TOWN MEDICAL CENTRE E85617
ELMBANK SURGERY E85088
GURU NANAK MEDICAL CENTRE E85121
ALLENBY CLINIC E85105
BROADMEAD SURGERY E85715
THE PITSHANGER LANE SURGERY E85714
WEST END SURGERY E85064
THE NORTHCOTE MEDICAL CENTRE E85733
SUNRISE MEDICAL CENTRE E85656
HILLVIEW SURGERY E85054
ELTHORNE PARK SURGERY E85628
THE MWH PRACTICE E85119
THE CUCKOO LANE PRACTICE E85116
QUEENS WALK PRACTICE E85057
GROSVENOR HOUSE SURGERY E85034
KS MEDICAL CENTRE E85012
THE AVENUE SURGERY E85099
HAMMOND ROAD SURGERY E85090
DR SIVANESAN & PARTNER E85083
LADY MARGARET ROAD MEDICAL CENTRE E85103
CHEPSTOW GARDENS MEDICAL CENTRE E85023
NURSING HOME SERVICES Y04225
GP practice CCG
68
Heart failure prevalence by GP practice
• 1,966 people with diagnosed heart
failure in NHS Ealing CCG
• GP practice range: 0.1% to 7.6%
CVD: Primary Care Intelligence Packs
84.7%
82.7%
84.8%
86.0%
86.0%
87.6%
88.4%
91.5%
91.5%
0% 20% 40% 60% 80% 100%
England
NHS West London CCG
NHS Hammersmith And Fulham CCG
NHS Harrow CCG
NHS Central London (Westminster) CCG
NHS Hillingdon CCG
NHS Brent CCG
NHS Ealing CCG
NHS Hounslow CCG
Treatment No treatment Exceptions reported
69
Percentage of patients with heart failure due to left ventricular systolic dysfunction
(LVSD) who are treated with ACE-I / ARB by CCG
Comparison with CCGs in the STP
• 293 people with heart failure* with
LVSD in NHS Ealing CCG
• 268 (91.5%) people treated with ACE-
I or ARB
• 24 (8.2%) people who are exceptions
• 1 (0.3%) additional people who are
not treated with ACE-I or ARB
*Using the QOF clinical indicator HF003
denominator plus exceptions
CVD: Primary Care Intelligence Packs
83.4%
86.0%
87.0%
87.2%
87.3%
87.6%
88.4%
88.7%
89.3%
91.5%
91.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Birmingham South and Central CCG
NHS Harrow CCG
NHS Leicester City CCG
NHS Sandwell and West Birmingham CCG
NHS Merton CCG
NHS Hillingdon CCG
NHS Brent CCG
NHS Waltham Forest CCG
NHS Redbridge CCG
NHS Ealing CCG
NHS Hounslow CCG
Treatment No treatment Exceptions reported
70
Percentage of patients with heart failure due to left ventricular systolic dysfunction
(LVSD) who are treated with ACE-I / ARB by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
2
1
2
1
1
1
1
2
1
1
4
2
1
1
1
1
1
1
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ISLIP MANOR MEDICAL CENTRE E85098
THE BURLINGTON GARDENS SURGERY E85705
NURSING HOME SERVICES Y04225
JUBILEE GARDENS MEDICAL CENTRE E85745
ST.GEORGES MEDICAL CTR. E85743
RIBCHESTER MEDICAL CENTRE E85728
MATTOCK LANE HEALTH CENTRE E85726
THE GROVE MEDICAL PRACTICE E85725
NORTHOLT FAMILY PRACTICE E85723
THE TOWN SURGERY E85721
BROADMEAD SURGERY E85715
ACTON LANE MEDICAL CENTRE E85687
DORMERS WELLS MEDICAL CENTRE E85682
CLOISTER ROAD SURGERY E85680
THE HORN LANE SURGERY E85677
THE SALUJA CLINIC E85663
EALING PARK HEALTH CENTRE E85657
SUNRISE MEDICAL CENTRE E85656
MEADOW VIEW E85643
THE CHURCHFIELD ROAD SURGERY E85640
THE VALE SURGERY E85635
THE SOUTHALL MEDICAL CTR. E85633
WESTERN AVENUE SURGERY E85630
SOMERSET MEDICAL CENTRE E85623
ACTON TOWN MEDICAL CENTRE E85617
CHISWICK FAMILY PRACTICE E85130
THE MANSELL ROAD PRACTICE E85129
THE BARNABAS MEDICAL CTRE E85127
THE CORFTON ROAD SURGERY E85123
GURU NANAK MEDICAL CENTRE E85121
THE ARGYLE SURGERY E85120
THE MWH PRACTICE E85119
THE CUCKOO LANE PRACTICE E85116
ELMTREES SURGERY E85112
PERIVALE MEDICAL CLINIC E85111
MANDEVILLE MEDICAL CENTRE E85108
THE MILL HILL SURGERY E85107
LADY MARGARET ROAD MEDICAL CENTRE E85103
THE AVENUE SURGERY E85099
MEDICAL CENTRE E85096
BRUNSWICK ROAD MED.CTR. E85091
HAMMOND ROAD SURGERY E85090
ELMBANK SURGERY E85088
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
OLDFIELD FAMILY PRACTICE E85069
THE BEDFORD PARK SURGERY E85066
WEST END SURGERY E85064
WELCOME PRACTICE E85061
HILLVIEW SURGERY E85054
THE MEDICAL CENTRE E85053
GREENFORD AVENUE FHP E85051
BELMONT MEDICAL CENTRE E85049
EASTMEAD AVENUE SURGERY E85046
HANWELL HEALTH CENTRE (NAISH) E85041
GROSVENOR HOUSE SURGERY E85034
CHEPSTOW GARDENS MEDICAL CENTRE E85023
YEADING MEDICAL CENTRE E85021
HANWELL HEALTH CENTRE (STEWART) E85013
KS MEDICAL CENTRE E85012
WATERSIDE MEDICAL CENTRE E85006
THE ALLENDALE ROAD SURGERY E84059
ELTHORNE PARK SURGERY E85628
DR SIVANESAN & PARTNER E85083
THE FLORENCE ROAD SURGERY E85122
GORDON HOUSE SURGERY E85026
QUEENS WALK PRACTICE E85057
THE PITSHANGER LANE SURGERY E85714
GOODCARE PRACTICE E85712
HILLCREST SURGERY E85028
THE BOILEAU ROAD SURGERY E85694
THE ACTON HEALTH CENTRE E85109
GREENFORD ROAD MED.CTR. E85050
NORTHFIELDS SURGERY E85014
FEATHERSTONE ROAD HEALTH CENTRE Y02342
SOMERSET FHP O Y01221
THE LYNWOOD SURGERY E85740
THE NORTHCOTE MEDICAL CENTRE E85733
ALLENBY CLINIC E85105
CROWN STREET SURGERY E85019
No treatment Exceptions reported
71
Percentage of patients with heart failure due to left ventricular systolic dysfunction
(LVSD) who are not treated with ACE-I / ARB by GP practice
• in total, including exceptions, there
are 25 people who are not treated
with ACE-I or ARB
• GP practice range: 0.0% to 50.0%
CVD: Primary Care Intelligence Packs
77.7%
71.7%
72.6%
73.4%
74.0%
77.4%
82.5%
82.8%
83.6%
0% 20% 40% 60% 80% 100%
England
NHS Central London (Westminster) CCG
NHS Hillingdon CCG
NHS West London CCG
NHS Hammersmith And Fulham CCG
NHS Harrow CCG
NHS Brent CCG
NHS Hounslow CCG
NHS Ealing CCG
Treatment No treatment Exceptions reported
72
Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD)
who are treated with ACE-I / ARB and BB by CCG
Comparison with CCGs in the STP
• 268 people with heart failure* with
LVSD treated with ACE-I/ARB in NHS
Ealing CCG
• 224 (83.6%) people treated with ACE-
I/ARB and BB
• 31 (11.6%) people who are
exceptions
• 13 (4.9%) additional people who are
not treated with ACE-I/ARB and BB
*Using the QOF clinical indicator HF004
denominator plus exceptions
CVD: Primary Care Intelligence Packs
70.3%
70.6%
72.6%
73.5%
74.5%
77.4%
79.4%
79.9%
82.5%
82.8%
83.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Birmingham South and Central CCG
NHS Sandwell and West Birmingham CCG
NHS Hillingdon CCG
NHS Redbridge CCG
NHS Waltham Forest CCG
NHS Harrow CCG
NHS Leicester City CCG
NHS Merton CCG
NHS Brent CCG
NHS Hounslow CCG
NHS Ealing CCG
Treatment No treatment Exceptions reported
73
Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD)
who are treated with ACE-I / ARB and BB by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
1
2
1
1
1
3
1
1
1
7
1
2
1
1
1
2
3
5
2
1
2
1
1
1
1
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ISLIP MANOR MEDICAL CENTRE E85098
THE BURLINGTON GARDENS SURGERY E85705
NURSING HOME SERVICES Y04225
FEATHERSTONE ROAD HEALTH CENTRE Y02342
SOMERSET FHP O Y01221
ST.GEORGES MEDICAL CTR. E85743
THE LYNWOOD SURGERY E85740
THE NORTHCOTE MEDICAL CENTRE E85733
RIBCHESTER MEDICAL CENTRE E85728
MATTOCK LANE HEALTH CENTRE E85726
THE GROVE MEDICAL PRACTICE E85725
NORTHOLT FAMILY PRACTICE E85723
THE TOWN SURGERY E85721
BROADMEAD SURGERY E85715
THE PITSHANGER LANE SURGERY E85714
GOODCARE PRACTICE E85712
THE BOILEAU ROAD SURGERY E85694
DORMERS WELLS MEDICAL CENTRE E85682
THE HORN LANE SURGERY E85677
THE SALUJA CLINIC E85663
SUNRISE MEDICAL CENTRE E85656
MEADOW VIEW E85643
THE CHURCHFIELD ROAD SURGERY E85640
THE VALE SURGERY E85635
THE SOUTHALL MEDICAL CTR. E85633
WESTERN AVENUE SURGERY E85630
SOMERSET MEDICAL CENTRE E85623
ACTON TOWN MEDICAL CENTRE E85617
CHISWICK FAMILY PRACTICE E85130
THE MANSELL ROAD PRACTICE E85129
THE CORFTON ROAD SURGERY E85123
GURU NANAK MEDICAL CENTRE E85121
ELMTREES SURGERY E85112
MANDEVILLE MEDICAL CENTRE E85108
ALLENBY CLINIC E85105
LADY MARGARET ROAD MEDICAL CENTRE E85103
THE AVENUE SURGERY E85099
MEDICAL CENTRE E85096
BRUNSWICK ROAD MED.CTR. E85091
HAMMOND ROAD SURGERY E85090
ELMBANK SURGERY E85088
WEST END SURGERY E85064
WELCOME PRACTICE E85061
HILLVIEW SURGERY E85054
THE MEDICAL CENTRE E85053
GREENFORD AVENUE FHP E85051
GREENFORD ROAD MED.CTR. E85050
BELMONT MEDICAL CENTRE E85049
HANWELL HEALTH CENTRE (NAISH) E85041
GROSVENOR HOUSE SURGERY E85034
GORDON HOUSE SURGERY E85026
CHEPSTOW GARDENS MEDICAL CENTRE E85023
CROWN STREET SURGERY E85019
KS MEDICAL CENTRE E85012
THE FLORENCE ROAD SURGERY E85122
EASTMEAD AVENUE SURGERY E85046
THE MILL HILL SURGERY E85107
DR SIVANESAN & PARTNER E85083
THE ARGYLE SURGERY E85120
EALING PARK HEALTH CENTRE E85657
THE BARNABAS MEDICAL CTRE E85127
THE BEDFORD PARK SURGERY E85066
NORTHFIELDS SURGERY E85014
ELTHORNE PARK SURGERY E85628
THE MWH PRACTICE E85119
THE CUCKOO LANE PRACTICE E85116
PERIVALE MEDICAL CLINIC E85111
HANWELL HEALTH CENTRE (STEWART) E85013
WATERSIDE MEDICAL CENTRE E85006
QUEENS WALK PRACTICE E85057
HILLCREST SURGERY E85028
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
JUBILEE GARDENS MEDICAL CENTRE E85745
ACTON LANE MEDICAL CENTRE E85687
CLOISTER ROAD SURGERY E85680
THE ACTON HEALTH CENTRE E85109
OLDFIELD FAMILY PRACTICE E85069
YEADING MEDICAL CENTRE E85021
THE ALLENDALE ROAD SURGERY E84059
No treatment Exceptions reported
74
Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who
are not treated with ACE-I / ARB and BB by GP practice
• in total, including exceptions, there
are 44 people who are not treated
with ACE-I or ARB
• GP practice range: 0.0% to 50.0%
CVD: Primary Care Intelligence Packs
88.2%
83.9%
86.3%
86.5%
87.9%
88.0%
89.1%
89.5%
89.8%
0% 20% 40% 60% 80% 100%
England
NHS Hammersmith And Fulham CCG
NHS Central London (Westminster) CCG
NHS West London CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Hillingdon CCG
NHS Harrow CCG
NHS Brent CCG
Below 150/90 Not below 150/90 Exceptions reported
75
Percentage of patients with CHD whose blood pressure reading
(measured in the preceding 12 months) is 150/90 mmHg or less by CCG
Comparison with CCGs in the STP
*Using the QOF clinical indicator CHD002
denominator plus exceptions
• 10,433 people with coronary heart
disease* in NHS Ealing CCG
• 9,178 (88%) people whose blood
pressure <= 150 / 90
• 492 (4.7%) people who are
exceptions
• 763 (7.3%) additional people whose
blood pressure is not <= 150 / 90
CVD: Primary Care Intelligence Packs
87.0%
87.0%
87.9%
88.0%
88.9%
89.1%
89.5%
89.5%
89.8%
90.1%
90.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Sandwell and West Birmingham CCG
NHS Leicester City CCG
NHS Hounslow CCG
NHS Ealing CCG
NHS Waltham Forest CCG
NHS Hillingdon CCG
NHS Harrow CCG
NHS Merton CCG
NHS Brent CCG
NHS Redbridge CCG
NHS Birmingham South and Central CCG
Below 150/90 Not below 150/90 Exceptions reported
76
Percentage of patients with CHD whose blood pressure reading
(measured in the preceding 12 months) is 150/90 mmHg or less by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
1
1
2
2
3
5
5
3
5
6
2
5
8
9
10
8
6
17
6
4
8
6
5
26
23
18
17
26
12
23
7
15
14
21
10
9
15
21
21
16
21
8
25
32
23
15
14
24
10
8
13
41
21
21
18
16
51
21
17
18
11
16
33
13
12
38
19
19
23
14
3
9
48
50
20
31
58
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
THE TOWN SURGERY E85721
THE BURLINGTON GARDENS SURGERY E85705
CHISWICK FAMILY PRACTICE E85130
RIBCHESTER MEDICAL CENTRE E85728
THE HORN LANE SURGERY E85677
ALLENBY CLINIC E85105
HANWELL HEALTH CENTRE (STEWART) E85013
NORTHOLT FAMILY PRACTICE E85723
ELMBANK SURGERY E85088
SOMERSET MEDICAL CENTRE E85623
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
CHEPSTOW GARDENS MEDICAL CENTRE E85023
BRUNSWICK ROAD MED.CTR. E85091
MATTOCK LANE HEALTH CENTRE E85726
THE CUCKOO LANE PRACTICE E85116
THE SOUTHALL MEDICAL CTR. E85633
ELTHORNE PARK SURGERY E85628
GOODCARE PRACTICE E85712
BROADMEAD SURGERY E85715
THE SALUJA CLINIC E85663
WATERSIDE MEDICAL CENTRE E85006
WESTERN AVENUE SURGERY E85630
THE MEDICAL CENTRE E85053
ST.GEORGES MEDICAL CTR. E85743
THE AVENUE SURGERY E85099
GORDON HOUSE SURGERY E85026
SUNRISE MEDICAL CENTRE E85656
THE MANSELL ROAD PRACTICE E85129
HAMMOND ROAD SURGERY E85090
QUEENS WALK PRACTICE E85057
WEST END SURGERY E85064
KS MEDICAL CENTRE E85012
THE CHURCHFIELD ROAD SURGERY E85640
DR SIVANESAN & PARTNER E85083
CLOISTER ROAD SURGERY E85680
THE BARNABAS MEDICAL CTRE E85127
OLDFIELD FAMILY PRACTICE E85069
WELCOME PRACTICE E85061
GREENFORD AVENUE FHP E85051
NORTHFIELDS SURGERY E85014
MEDICAL CENTRE E85096
THE GROVE MEDICAL PRACTICE E85725
EALING PARK HEALTH CENTRE E85657
THE VALE SURGERY E85635
GREENFORD ROAD MED.CTR. E85050
HILLVIEW SURGERY E85054
GROSVENOR HOUSE SURGERY E85034
MEADOW VIEW E85643
HANWELL HEALTH CENTRE (NAISH) E85041
DORMERS WELLS MEDICAL CENTRE E85682
FEATHERSTONE ROAD HEALTH CENTRE Y02342
PERIVALE MEDICAL CLINIC E85111
ACTON TOWN MEDICAL CENTRE E85617
THE FLORENCE ROAD SURGERY E85122
HILLCREST SURGERY E85028
YEADING MEDICAL CENTRE E85021
LADY MARGARET ROAD MEDICAL CENTRE E85103
THE MILL HILL SURGERY E85107
GURU NANAK MEDICAL CENTRE E85121
THE ARGYLE SURGERY E85120
THE CORFTON ROAD SURGERY E85123
MANDEVILLE MEDICAL CENTRE E85108
THE ACTON HEALTH CENTRE E85109
SOMERSET FHP O Y01221
CROWN STREET SURGERY E85019
ISLIP MANOR MEDICAL CENTRE E85098
THE NORTHCOTE MEDICAL CENTRE E85733
THE MWH PRACTICE E85119
THE ALLENDALE ROAD SURGERY E84059
ELMTREES SURGERY E85112
BELMONT MEDICAL CENTRE E85049
THE BEDFORD PARK SURGERY E85066
ACTON LANE MEDICAL CENTRE E85687
THE LYNWOOD SURGERY E85740
JUBILEE GARDENS MEDICAL CENTRE E85745
EASTMEAD AVENUE SURGERY E85046
THE BOILEAU ROAD SURGERY E85694
THE PITSHANGER LANE SURGERY E85714
NURSING HOME SERVICES Y04225
Not below 150/90 Exceptions reported
77
Percentage of patients with CHD whose blood pressure reading
(measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice
• in total, including exceptions, there
are 1,255 people whose blood
pressure is not <= 150 / 90
• GP practice range: 0.0% to 35.6%
CVD: Primary Care Intelligence Packs
25
15
36
32
6
2
9
15
12
12
-30%-25%-20%-15%-10%-5%0%5%10%
THE PITSHANGER LANE SURGERY
THE BOILEAU ROAD SURGERY
EASTMEAD AVENUE SURGERY
JUBILEE GARDENS MEDICAL CENTRE
THE LYNWOOD SURGERY
ACTON LANE MEDICAL CENTRE
THE BEDFORD PARK SURGERY
BELMONT MEDICAL CENTRE
ELMTREES SURGERY
THE ALLENDALE ROAD SURGERY
ELMBANK SURGERY
NORTHOLT FAMILY PRACTICE
HANWELL HEALTH CENTRE (STEWART)
ELTHORNE PARK SURGERY
THE HORN LANE SURGERY
ALLENBY CLINIC
RIBCHESTER MEDICAL CENTRE
CHISWICK FAMILY PRACTICE
THE TOWN SURGERY
THE BURLINGTON GARDENS SURGERY
78
Percentage of patients with CHD whose blood pressure reading (measured
in the preceding 12 months) is not 150/90 mmHg or less by GP practice –
opportunities compared to GP cluster
• using the GP cluster method of
calculating potential gains, if each
practice was to achieve as well as the
upper quartile of its national cluster,
then an additional 534 people would
be treated
CVD: Primary Care Intelligence Packs
Details of this methodology are available on slide
9. Click here to view them.
91.8%
87.9%
88.4%
89.1%
91.8%
92.4%
92.8%
93.3%
93.5%
0% 20% 40% 60% 80% 100%
England
NHS Hammersmith And Fulham CCG
NHS West London CCG
NHS Central London (Westminster) CCG
NHS Hounslow CCG
NHS Harrow CCG
NHS Ealing CCG
NHS Brent CCG
NHS Hillingdon CCG
Optimal management No treatment Exceptions reported
79
Percentage of patients with CHD with a record in the preceding 12 months that aspirin,
an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG
Comparison with CCGs in the STP
*Using the QOF clinical indicator CHD005
denominator plus exceptions
• 10,433 people with coronary heart
disease* in NHS Ealing CCG
• 9,679 (92.8%) people who are taking
aspirin, an alternative anti-platelet
therapy, or an anti-coagulant
• 359 (3.4%) people who are
exceptions
• 395 (3.8%) additional people who are
not taking aspirin, an alternative anti-
platelet therapy, or an anti-coagulant
CVD: Primary Care Intelligence Packs
89.9%
90.7%
91.8%
92.0%
92.4%
92.7%
92.8%
92.9%
93.3%
93.4%
93.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
NHS Leicester City CCG
NHS Sandwell and West Birmingham CCG
NHS Hounslow CCG
NHS Waltham Forest CCG
NHS Harrow CCG
NHS Redbridge CCG
NHS Ealing CCG
NHS Merton CCG
NHS Brent CCG
NHS Birmingham South and Central CCG
NHS Hillingdon CCG
Optimal management No treatment Exceptions reported
80
Percentage of patients with CHD with a record in the preceding 12 months that aspirin,
an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG
Comparison with demographically similar CCGs
CVD: Primary Care Intelligence Packs
3
2
1
1
2
3
3
3
2
7
3
3
4
3
4
4
6
3
3
12
4
3
4
3
4
5
3
14
3
12
4
12
6
13
1
10
13
5
16
9
10
11
8
18
12
25
15
18
6
31
10
4
18
18
12
19
18
19
16
15
8
11
32
23
18
11
18
12
10
17
24
51
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
THE TOWN SURGERY E85721
GOODCARE PRACTICE E85712
THE BURLINGTON GARDENS SURGERY E85705
WESTERN AVENUE SURGERY E85630
ALLENBY CLINIC E85105
BRUNSWICK ROAD MED.CTR. E85091
THE ALLENDALE ROAD SURGERY E84059
THE SALUJA CLINIC E85663
THE SOUTHALL MEDICAL CTR. E85633
SOMERSET MEDICAL CENTRE E85623
RIBCHESTER MEDICAL CENTRE E85728
ELMBANK SURGERY E85088
LADY MARGARET ROAD MEDICAL CENTRE E85103
BELMONT MEDICAL CENTRE E85049
MANDEVILLE MEDICAL CENTRE E85108
FEATHERSTONE ROAD HEALTH CENTRE Y02342
JUBILEE GARDENS MEDICAL CENTRE E85745
THE MEDICAL CENTRE E85053
BROADMEAD SURGERY E85715
MEADOW VIEW E85643
SOUTHFIELD MEDICAL CENTRE (WEBER) E85075
CHEPSTOW GARDENS MEDICAL CENTRE E85023
ELMTREES SURGERY E85112
DR SIVANESAN & PARTNER E85083
THE CHURCHFIELD ROAD SURGERY E85640
WATERSIDE MEDICAL CENTRE E85006
GORDON HOUSE SURGERY E85026
NORTHOLT FAMILY PRACTICE E85723
THE NORTHCOTE MEDICAL CENTRE E85733
THE PITSHANGER LANE SURGERY E85714
HANWELL HEALTH CENTRE (STEWART) E85013
MATTOCK LANE HEALTH CENTRE E85726
SOMERSET FHP O Y01221
PERIVALE MEDICAL CLINIC E85111
QUEENS WALK PRACTICE E85057
THE AVENUE SURGERY E85099
GREENFORD ROAD MED.CTR. E85050
THE VALE SURGERY E85635
THE BARNABAS MEDICAL CTRE E85127
OLDFIELD FAMILY PRACTICE E85069
EASTMEAD AVENUE SURGERY E85046
ACTON LANE MEDICAL CENTRE E85687
HILLCREST SURGERY E85028
CROWN STREET SURGERY E85019
CHISWICK FAMILY PRACTICE E85130
SUNRISE MEDICAL CENTRE E85656
THE CUCKOO LANE PRACTICE E85116
THE GROVE MEDICAL PRACTICE E85725
YEADING MEDICAL CENTRE E85021
HANWELL HEALTH CENTRE (NAISH) E85041
KS MEDICAL CENTRE E85012
ELTHORNE PARK SURGERY E85628
THE FLORENCE ROAD SURGERY E85122
EALING PARK HEALTH CENTRE E85657
THE MWH PRACTICE E85119
ST.GEORGES MEDICAL CTR. E85743
GURU NANAK MEDICAL CENTRE E85121
THE MILL HILL SURGERY E85107
THE LYNWOOD SURGERY E85740
THE MANSELL ROAD PRACTICE E85129
DORMERS WELLS MEDICAL CENTRE E85682
WEST END SURGERY E85064
NORTHFIELDS SURGERY E85014
HAMMOND ROAD SURGERY E85090
MEDICAL CENTRE E85096
THE ARGYLE SURGERY E85120
CLOISTER ROAD SURGERY E85680
THE ACTON HEALTH CENTRE E85109
ACTON TOWN MEDICAL CENTRE E85617
HILLVIEW SURGERY E85054
GROSVENOR HOUSE SURGERY E85034
GREENFORD AVENUE FHP E85051
WELCOME PRACTICE E85061
THE CORFTON ROAD SURGERY E85123
THE BOILEAU ROAD SURGERY E85694
THE HORN LANE SURGERY E85677
THE BEDFORD PARK SURGERY E85066
ISLIP MANOR MEDICAL CENTRE E85098
NURSING HOME SERVICES Y04225
No treatment Exceptions reported
81
Percentage of patients with CHD without a record in the preceding 12 months that aspirin,
an alternative anti-platelet therapy, or an anti-coagulant is being taken by GP practice
• in total, including exceptions, there
are 754 people are not taking aspirin,
an alternative anti-platelet therapy, or
an anti-coagulant
• GP practice range: 0.0% to 31.3%
CVD: Primary Care Intelligence Packs
Some data on outcomes for people with
cardiovascular disease
82 CVD: Primary Care Intelligence Packs
0
200
400
600
800
1000
1200
1400
1600
2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16
Ag
e s
tand
ard
ise
d r
ate
(p
er
100
,00
0)
NHS Ealing CCG England
83
Hospital admissions for coronary heart disease for all ages 2002/03 – 2015/16
Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
• in NHS Ealing CCG, the hospital
admission rate for coronary heart
disease in 2015/16 was 832.3 (1,982)
compared to 527.9 for England
CVD: Primary Care Intelligence Packs
0
50
100
150
200
250
2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16
Age s
tandard
ised r
ate
(p
er
100,0
00)
NHS Ealing CCG England
84
Hospital admissions for stroke for all ages 2002/03 – 2015/16
Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved
• in NHS Ealing CCG, the hospital
admission rate for stroke in 2015/16
was 193.2 (442) compared to 172.8
for England
CVD: Primary Care Intelligence Packs
293.0%
753.5%
445.8%
81.3%
150.0%
108.6%
136.8%
342.2%
442.0%
292.3%
76.0%
146.4%
131.3%
163.0%
0% 100% 200% 300% 400% 500% 600% 700% 800%
RRT
Minor amputation
Major amputation
Stroke
Heart failure
Heart Attack
Angina
NHS Ealing CCG England
85
Additional risk of complications for people with diabetes, three year follow up, 2013/14
Note: This slide uses data from the National
Diabetes Audit (NDA)
• The risk of a stroke was 76% higher
and the risk of a heart attack was
131.3% higher compared to people
without diabetes. The risk of a major
amputation was 292.3% higher.
CVD: Primary Care Intelligence Packs
0
10
20
30
40
50
60
70
80
90
100
2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Ag
e s
tand
ard
ise
d r
ate
(p
er
100
0,0
00
)
NHS Ealing CCG England
86
Deaths from coronary heart disease, under 75s
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
• in NHS Ealing CCG, the early
mortality rate for coronary heart
disease in 2013-15 was 47.6,
compared to 40.6 for England
CVD: Primary Care Intelligence Packs
0
5
10
15
20
25
30
2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15
Ag
e s
tand
ard
ise
d r
ate
(p
er
100
,00
0)
NHS Ealing CCG England
87
Deaths from stroke, under 75s
Source: Office for National Statistics (ONS) mortality data 2002 - 2015
• in NHS Ealing CCG, the early
mortality rate for stroke in 2013-15
was 13.1, compared to 13.6 for
England
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Appendix Data sources
• Quality and Outcomes Framework (QOF), 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights
reserved
• Non-diabetic hyperglycaemia prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/nhs-diabetes-
prevention-programme-non-diabetic-hyperglycaemia
• Diabetes prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for-
local-populations
• CKD Prevalence model, G.Aitken, University of Southampton , 2014 https://www.gov.uk/government/publications/ckd-
prevalence-estimates-for-local-and-regional-populations
• Hypertension prevalence estimates for local CCG populations. Created using data from: QOF hypertension registers 2014/15
and; Undiagnosed hypertension estimates for adults 16 years and older. 2014. Department of Primary Care & Public Health,
Imperial College London https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations
• NHS Stop smoking services Copyright © 2014, NHS Digital
• Norberg J, Bäckström S , Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population
using validated electronic health data. Clin Epidemiol 2013 ; 5 475 – 81.
• National Diabetes Audit, 2013/14 and 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights
reserved
• Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights
reserved
• Office for National Statistics (ONS) mortality data 2002 – 2015, Copyright © 2017, Re-used with the permission of the Office for
National Statistics. All rights reserved
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