High Blood Pressure in General Practice: Variation and Opportunities South Cheshire CCG (v11) 5th March 2019

NHS RightCare Intelligence: ‘Similar 10’ Methodology The NHS RightCare data packs compare a CCG to its 10 most demographically similar CCGs. Since most health conditions are linked to factors such as deprivation and age, NHS RightCare compares systems to their closest demographically similar geographies. This is to provide realistic comparisons, taking into account the need for healthcare of different populations. Also included are some examples of how your CCG benchmarks against neighbouring Cheshire and Merseyside CCGs. It should be noted that these packs were produced using readily available data and analysis. For this reason, relevant time periods are not consistent throughout and this will explain some discrepancies observed. However, it is anticipated that the overall findings will not have varied significantly over the short time periods involved.

How to interpret the RightCare variation charts The chart at the top shows a national distribution of CCGs ranked from lowest value to highest value, left to right. The chart at the bottom shows each chosen CCG and the % variance from the lowest similar 5 CCGs. Red indicates an apparent unwarranted variation. Blue indicates that local interpretation is required

National Ambitions for High Blood Pressure https://app.box.com/s/4u4i5yxmvy404ue4scfdw4sytyd66ck3/file/400317380843

In this South Cheshire High Blood Pressure data pack High BP data Detection/ diagnosis (prevalence) Treatment and control (including prescribing costs & local insights) Impacts of high BP (medical complications, hospital admissions, deaths, spend) Lifestyle factors (smoking, alcohol, obesity, physical inactivity) Variation Between CCGs ‘Similar 10’ C&M CCGs Within own CCG Practice level data Opportunities Improve Care & Quality Improve Health & Wellbeing

Detection and Diagnosis of High Blood Pressure in South Cheshire CCG

How much hypertension is diagnosed? (C&M CCGs compared) Source: https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133106/pat/46/par/E39000026/ati/154/are/E38000208/iid/219/age/1/sex/4

What proportion of actual high BP is known?

Practice-level identification of high BP (Observed/ expected prevalence, 2016/17) Source: Cardiovascular Disease Primary Care Intelligence Packs. Public Health England. November 2018 * fingertips.phe.org.uk/profile/cardiovascular-disease-primary-care * The latest Primary Care Intelligence Packs do not include observed vs expected hypertension prevalence. These will be updated when a refreshed version of the hypertension prevalence model becomes available

BP checks in last 5 years (C&M CCGs compared) Good coverage of BP testing but diagnosis gap remains - Why? https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133106/pat/46/par/E39000026/ati/154/are/E38000208/iid/91262/age/251/sex/4

Meeting the national ambition for detection (80%) South Cheshire CCG need to find / diagnose a further 8,950 patients to meet the national ambition of 80% by 2029

Opportunities for South Cheshire: BP detection and diagnosis Case-finding: Estimated number with undiagnosed high BP (British Heart Foundation, 2016/17) 18,400 patients To meet national ambition of 80% detection by 2029 South Cheshire needs to find 8,950 patients If reported prevalence increased by 1% South Cheshire would have an additional 1,857 patients on the hypertension register If reported prevalence increased to the level of similar CCGs (NHS RightCare Reported to Estimated Prevalence, 2017/18) the hypertension register would be unchanged The following slides can be used by CCGs to understand the potential for improvement in case finding and control of hypertension. The figures presented have been sourced as follows: 1) British Heart Foundation – Blood Pressure: How can we do better? Estimated number with undiagnosed high BP – the total number of undetected cases, calculated as the gap between the estimated number of people with hypertension and those who have been diagnosed. 2) Increase of 1% in reported cases of hypertension This applies the 1% improvement, seen in Bradford Districts CCG following the Healthy Hearts programme, to show the impact if this effect was replicated across the STP. 3) NHS RightCare 2017/18 Quality and Outcomes Framework (QOF) data pack These figures show variation from the highest performing similar CCGs, and give an indication of what is possible based on the achievement of demographically matched peers.

Management and Control of High Blood Pressure in South Cheshire Controlling high BP ‘to target’ Prescribing spend Other measures of quality BP care

Measuring how well BP is controlled Quality and Outcomes Framework (QoF): Source of routinely available data but underestimates the scale of the challenge Current QoF target BP is <150/90mmHg but plan is to align QoF with NICE BP targets National Institute for Health and Care Excellence, NICE (‘gold standard’): BP target lower at <140/90mmHg (varies with co-morbidities/age 80+) Series of auditable NICE Quality Standards Performance against NICE guidelines: Patchy knowledge National Ambitions for high BP (launched Feb 2019) Ambition: 80% known BP patients treated to NICE targets by 2029 Nationally ~56% known BP patients treated to NICE targets In South Cheshire CCG ~16,500 known BP patients estimated to be treated to NICE targets To meet the national ambition South Cheshire CCG needs an estimated ~7,100 additional BP patients to be managed to NICE BP targets over the next 10 years

BP control to QoF target (C&M CCGs compared) https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133106/pat/46/par/E39000026/ati/154/are/E38000208/iid/91089/age/1/sex/4

BP Control: Comparing South Cheshire with 10 similar CCGs

% High BP patients not managed to <150/90mmHg (by practice) Using QOF 17/18 Source: Cardiovascular Disease Primary Care Intelligence Packs. Public Health England. February 2019 fingertips.phe.org.uk/profile/cardiovascular-disease-primary-care

Other measures of Quality: Local insights into common areas of variation and uncertainty Diagnosis Use of Ambulatory/ Home BP Monitoring Recording of stage 1 hypertension New patient Investigations Assessment for target organ damage: Blood tests Urine Eyes ECG Management Lack of equipment   Investigation of <40’s Assessing CVD/Q risk Lifestyle advice Setting BP targets Recall methodology Annual review content Exception reporting Control QoF (150/90) vs NICE (140/90) targets Coding: Not standardised Practice-level data: unaware of performance/benchmarking Skill mix and workforce development in general practice Models of care: working with system partners, capacity-building Highlights that control to QoF target of 150/90 not the only measure of, or issue with, delivery of quality BP care in general practice.

Primary care prescribing: High blood pressure and cholesterol medications

South Cheshire Primary Care Prescribing Spend: BP medication (Spend is often preventative spend)

South Cheshire Primary Care Prescribing Spend: CHD

South Cheshire Primary Care Prescribing Spend: Stroke

Statin prescribing for high CVD risk BP patients (C&M CCGs compared) https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133106/pat/46/par/E39000026/ati/154/are/E38000208/iid/91248/age/256/sex/4

Opportunities for South Cheshire: BP treatment & control Improve control of known BP patients: To meet the national ambition of 80% control by 2029, South Cheshire CCG needs an estimated ~7,100 additional BP patients to be managed to NICE BP targets If South Cheshire CCG matches performance of similar CCGs (high BP control to current QoF target) 521 more patients will be controlled to 150/90mmHg Reduce practice-level variation in control: % patients not controlled to 150/90mmHg ranges from 10.3% to 29.9% Address issues highlighted locally regarding variation and uncertainty in BP care

On Patients On Services Impacts of High BP On Patients On Services

The National Cost of High Blood Pressure Graphic - https://www.gov.uk/government/publications/health-matters-combating-high-blood-pressure/health-matters-combating-high-blood-pressure Complications include: Coronary Heart Disease Abnormal heart rhythms and stroke Chronic Kidney Disease Vascular dementia

Coronary Heart Disease Prevalence

Coronary Heart Disease Admission Rate (C&M CCGs compared) https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133108/pat/46/par/E39000026/ati/154/are/E38000208/iid/90988/age/1/sex/4

CHD Inpatient Spend and Bed Days

CHD Premature Mortality Rate (C&M CCGs compared) https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133108/pat/46/par/E39000026/ati/154/are/E38000208/iid/91059/age/163/sex/4

Atrial Fibrillation (AF) Prevalence

Inpatient Bed Days for Abnormal Heart Rhythm

Stroke Prevalence

Stroke admission rates (C&M CCGs compared) https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133110/pat/46/par/E39000026/ati/154/are/E38000208/iid/90986/age/1/sex/4

Stroke spend and bed days

Premature stroke mortality (C&M CCGs compared) https://fingertips.phe.org.uk/profile-group/cardiovascular-disease-diabetes-kidney-disease/profile/cardiovascular/data#page/3/gid/1938133110/pat/46/par/E39000026/ati/154/are/E38000208/iid/91061/age/163/sex/4

Chronic Kidney Disease Prevalence

Dementia Prevalence

Opportunities to Make Every Contact Count (MECC) in general practice

https://app.box.com/s/4u4i5yxmvy404ue4scfdw4sytyd66ck3/file/400323028477

Adult Obesity in South Cheshire (compared with C&M CCGs)

Adult obesity prevalence

Adult Smoking Prevalence (compared with C&M CCGs) https://fingertips.phe.org.uk/search/smoking%20prev#page/3/gid/1/pat/46/par/E39000026/ati/152/are/E38000056/iid/91280/age/188/sex/4

Adult Smoking Prevalence

Alcohol-specific admissions

Physically inactive adults

High Blood Pressure Key Opportunities for South Cheshire CCG Improve care quality (diagnosis & control) Improve health and wellbeing

Opportunities to improve Care Quality Improve detection & diagnosis Estimated number with undiagnosed high BP (British Heart Foundation, 2016/17) 18,400 patients To meet national ambition of 80% detection by 2029 South Cheshire needs to find 8,950 patients Reduce practice-level variation in detection (varies from 58% to 66%) Improve treatment to target (Control) To meet the national ambition of 80% control by 2029, South Cheshire CCG needs an estimated ~7,100 additional BP patients to be managed to NICE BP targets If South Cheshire CCG matches performance of similar CCGs (high BP control to current QoF target) 521 more patients will be controlled to 150/90mmHg Reduce practice-level variation in % patients not controlled to 150/90mmHg (ranges from 10% to 30%)

Opportunities to improve Health & Wellbeing Reduce lifestyle risk factors Lifestyle factors contributing to high BP and CVD risk are common, e.g. Harmful alcohol intake – South Cheshire has a higher rate of alcohol-specific admissions than peers Obesity– South Cheshire has a lower obesity rate than peers Smoking – South Cheshire has a similar smoking rate to peers Prevent complications of high BP Prevalence of CKD and dementia are higher than similar CCGs Prevent early deaths Premature mortality rate is similar to national average for stroke and CKD