Support for Regional Medical Directors Challenging Variation Innovation Scorecard January 2016

A key aim of NHS England is to increase appropriate uptake and reduce variation in the utility of new innovative treatments. In the first four years of the Innovation strategy we have seen promising signs of improved growth rates, but this still needs to improve; To do this, we need to harness the influence of Regional Medical Directors and National Clinical Directors, to challenge CCGs and Trusts where uptake is variable and unexplained. Data analyzed in these slides are from the January 2016 Innovation Scorecard published by the Health and Social Care InformationInnovation Scorecard published by the Health and Social Care Information This guide has been designed to help identify areas of variation of utility of innovative medicines, and stimulate discussion where variation occurs. The hyperlinks work when showing as a slideshow. Introduction How to use this guide Background to the medicine, including NICE’s view on its role in treatment Top and bottom usage CCGs for particular drug, with trend over last 4 quarters. Graph showing range of variation across country, from highest to lowest utility by CCG Link to online heat map to look at data interactively Heat map, with CCGs split into 5 quintiles of activity. 2 Medicines are measured in DDD(defined daily dosage) or ADD (actual daily dosage) or mg where these are not available.

Canagliflozin – Primary care Background This an option for treatment of type 2 diabetes recommended in NICE TA (TA315) published in July 2011 for use in combination with insulin with or without other antidiabetic drugs for people with type 2 diabetes. Treatment decisions are complex and local knowledge should inform analysis of this information. The National Diabetes Audit report on complications can be found hereTA315here Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority); CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. mgs per 100,000 Resident population Key lines of enquiry Significant variation in uptake can be seen on the maps below, with some areas having no access. Have the CCGs identified local barriers to the use of this treatment in both primary care and secondary care ? Lowest CCGs in region RegionTrend Nottingham West CCG0M. North Tyneside CCG0N. Sutton CCG12,012L ↑ Highest CCGs in region Oldham CCG1,647,892N ↑ South eastern Hampshire CCG1,155,014S ↑ South West Lincolnshire CCG803,658M ↑ Click here to see interactive heat map online

Diabetes Group– Primary care Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have the CCGs identified any local barriers to the use of this treatment in both primary care and secondary care ? Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Background This group of treatments includes Dapagliflozin, Exenatide and Liraglutide are recommended as options for the treatment of type 2 diabetes, including several NICE TAs: (TA288,TA248,NG28). Treatment decisions are complex and local knowledge should inform analysis of this information. The National Diabetes Audit report on complications can be found hereTA288TA248NG28here Lowest CCGs in region RegionTrend Great Yarmouth and Waveney CCG2,458M ↔ North Tyneside CCG3,095N ↑ Aylesbury Vale CCG3,498S ↑ Highest CCGs in region Wolverhampton CCG39,843M ↑ Swale CCG35,982S ↑ Blackpool CCG35,368N ↑ DDDs per 100,000 Resident population

Denosumab 60mgs – Primary care Background This is one option for treatment recommended by NICE TA (TA204) published in October 2010, for preventing bone fractures in some postmenopausal women with osteoporosis. Treatment decisions are complex and local knowledge should inform analysis of this information. Denosumab was a priority work-stream for the NICE Implementation Collaborative in its first year.TA204 For more information click hereclick here Key lines of enquiry Some areas do not appear to have access to this treatment. Have the CCGs identified local barriers to the use of this treatment in both primary care and secondary care? 5 DDDs per 100,000 Resident population Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ;CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Lowest CCGs in region RegionTrend Windsor, Ascot and Maidenhead CCG0S. Wigan Borough CCG0N ↓ Tower Hamlets CCG0L. Highest CCGs in region Southampton CCG5,378S ↑ Harrogate and Rural District CCG2,574N ↑ Mid Essex CCG1,228M ↑

Dronedarone Hydrochloride – Primary care Background This is one treatment option recommended by NICE TA (TA197) published in August 2010, for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation. Treatment decisions are complex and local knowledge should inform analysis of this informationTA197 Key lines of enquiry Some areas do not appear to have access to this treatment. Have CCGs identified any local barriers to the use of this treatment in both primary care and secondary care ? 6 DDDs per 100,000 Resident population Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Lowest CCGs in region RegionTrend Tower Hamlets CCG0L. Harrogate and Rural District CCG0N. Swale CCG0S. Highest CCGs in region Hastings and Rother CCG7,359S ↔ Bolton CCG1,564N ↔ Walsall CCG1,202M ↔ Click here to see interactive heat map online

Ivabradine – Primary care Background This is one treatment option recommended by NICE TA: (TA267) published in November 2012, as a treatment for some people with chronic heart failure after standard treatment. Treatment decisions are complex and local knowledge should inform analysis of this informationTA267 Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have CCGs identified local barriers to the use of this treatment in both primary care and secondary care ? 7 DDDs per 100,000 Resident population Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Lowest CCGs in region RegionTrend Crawley CCG370S ↔ Islington CCG1,104L ↔ Bassetlaw CCG1,453N ↔ Highest CCGs in region Bradford City CCG18,731N ↔ Hastings and Rother CCG15,430S ↔ North Norfolk CCG11,020M ↔ Click here to see interactive heat map online

Nalmefene – Primary care Background Nalmefene is recommended as a treatment option for alcohol dependence by NICE (TA325) since November Treatment decisions are complex and local knowledge should inform analysis of this information.TA325 It is the topic of a NICE Implementation Collaborative work stream and further details can be found herehere DDDs per 100,000 Resident population Key lines of enquiry Some areas do not appear to have access to this treatment. Have CCGs identified local barriers to the use of this treatment in both primary care and secondary care, such as access to substance misuse services. Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) : CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Lowest CCGs in region RegionTrend Wyre Forest CCG0M - Windsor, Ascot and Maidenhead CCG0S - West Cheshire CCG0N - Highest CCGs in region West Lancashire CCG238N ↑ Wiltshire CCG214S ↑ Southport and Formby CCG207N ↑ Click here to see interactive heat map online

Novel Oral Anti-Coagulants (NOACs) – Primary care Background This group of treatments are recommended as a treatment option for the prevention of stroke in Atrial Fibrillation and the treatment and secondary prevention of Deep Vein Thrombosis and/or Pulmonary Embolism. (TA249, TA256, TA275, TA327) in several technology appraisals up to December Treatment decisions are complex and local knowledge should inform analysis of this information. It has been a topic in a NICE Implementation Collaborative for use in Atrial Fibrillation and a consensus statement on its use has been produced by Royal Colleges. Find out more hereTA249 TA256 TA275 TA327Find out more here Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have CCGs identified any local barriers to the use of this treatment in both primary care and secondary care ? ADD per 100,000 resident population Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Lowest CCGs in region RegionTrend Haringey CCG7,661L ↑ Thurrock CCG16,620M ↑ Leeds West CCG19,603N ↑ Highest CCGs in region Somerset CCG188,617S ↑ Scarborough and Ryedale CCG185,437N ↑ Castle Point and Rochford CCG167,337M ↑ Click here to see interactive heat map online

Rifaximin – Primary care Background Rifaximin is recommended as treatment by NICE (TA337) for preventing episodes of hepatic encephalopathy in people aged 18 years or older since March Treatment decisions are complex and local knowledge should inform analysis of this information.TA337 DDDs per 100,000 Resident population Key lines of enquiry Some areas do not appear to have access to this treatment. Have CCGs identified local barriers to the use of this treatment in both primary care and secondary care Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) : CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Lowest CCGs in region RegionTrend Wyre Forest CCG0M ↓ Harrogate and Rural District CCG0N. South Kent Coast CCG0S ↓ Highest CCGs in region Newcastle Gateshead CCG1,347N ↔ South Eastern Hampshire CCG889S ↔ Walsall CCG862M ↔ Click here to see interactive heat map online

Ticagrelor – Primary care Background This is a treatment option recommended by NICE TA (TA236) published in October 2011, combined with low- dose aspirin for up to a year for some people with acute coronary syndromes. Treatment decisions are complex and local knowledge should inform analysis of this information.TA236 Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have CCGs identified any local barriers to the use of this treatment in both primary care and secondary care ? 11 DDDs per 100,000 Resident population Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Lowest CCGs in region RegionTrend Nottingham North and East CCG113M ↓ Brighton and Hove CCG267S ↑ South Cheshire CCG520N ↔ Highest CCGs in region Barnsley CCG14,820N ↔ Lincolnshire East CCG14,034M ↔ Kernow CCG8,623S ↑ Click here to see interactive heat map online

Ratio of colonoscopy procedures to flexible sigmoidoscopy procedures by CCG. Background Flexible sigmoidoscopy is the preferred procedure in some clinical situations because sedation is not required, and it is quicker and carries less risk than colonoscopy. Further detail of the evidence base is available in the Atlas of Variation.Further detail of the evidence base is available in the Atlas of Variation Key Lines of enquiry Have CCGs and regional teams identified any local barriers to the use of this technology? Source: HES HSCIC, taken from Endoscopy CCG.xlsx. Note: Excludes all cases where age, sex, IMD or CCG is missing or not relevant. Click here to see interactive heat map online Lowest CCGs in region Ratio of coloscopy to flexible sigmoidoscopy RegionTrend Corby CCG0M. Southport and Formby CCG1N. Portsmouth CCG1S. Highest CCGs in region Doncaster CCG10N. North Hampshire CCG4S. Bromley CCG4L.

Rate of computed tomography (CT) colonoscopy procedures per population by CCG 13 Key lines of enquiry Have the CCGs and regional teams identified any local barriers to the use of this technology? Background Computed tomography (CT) colonoscopy is a relatively new radiological technique designed to image the colon and is minimally invasive with no need for sedation, although a laxative bowel preparation is sometimes still required. Whilst it is used to investigate patients with symptoms suggestive of colorectal cancer, and has been found to be as effective as optical colonoscopy in the diagnosis of colorectal cancer, it is less useful for the diagnosis of IBD because biopsy material is invariably required to support or refute the diagnosis. Further detail of the evidence base is available in the Atlas of Variation.Further detail of the evidence base is available in the Atlas of Variation. Lowest CCGs in region RegionTrend Newcastle North and East CCG0N. Swindon CCG0S. Wolverhampton CCG 0M. Highest CCGs in region Fareham and Gosport CCG108S ↓ Halton CCG75N ↑ Stoke on Trent CCG65M ↑ Procedures per 10,000 population Source: DID, taken from Colonoscopy Barium Enema Standardised Rates.xlsx. Note: Excludes all cases where age, sex, IMD or CCG is missing or not relevant. Click here to see interactive heat map online

Rate of dual-energy X-ray absorptiometry (DEXA) activity per weighted population by CCG 14 Background Dual-energy X-ray absorptiometry (DEXA) is a type of X-ray used to measure the density of bones, is more sensitive than a normal X-ray and is also safer in that it delivers a much lower dose of radiation. Following a suspected fragility fracture, investigation of bone density, for instance using DEXA, is advised such that osteoporosis treatment can be initiated to help prevent a subsequent fracture and the consequent considerable morbidity. Further detail of the evidence base is available in the Atlas of VariationFurther detail of the evidence base is available in the Atlas of Variation. Key lines of enquiry Have CCGs identified any local barriers to the use of this technology ? Lowest CCGs in region RegionTrend Isle of Wight CCG90S ↓ Corby CCG232S ↑ Bolton CCG478N ↑ Highest CCGs in region North, East, West Devon CCG19,568S ↑ Sheffield CCG14,420N ↓ Barnet CCG11,793L ↔ Sources: Numerator from the Monthly Diagnostics Waiting times and Activity return (DM01). Note: Denominator taken from CCG-weighted-populations NHS England. Click here to see interactive heat map online

Proportion of prevalent dialysis population on home based modalities (Home HD and PD) by CCG 15 Background People on home haemodialysis have the option to increase both the duration and frequency of their dialysis treatment, which often makes people feel better, and may be associated with a longer life. In England, the variation is ten-fold. Further detail of the evidence base is available in the Atlas of Variation Key lines of enquiry Have CCGs identified any local barriers to the use of this technology ? Sources:The data reported here have been supplied by the UK Renal Registry of the Renal Association. Lowest CCGs in region RegionTrend Bradford City CCG2N. Hammersmith and Fulham CCG4L. Aylesbury Vale CCG7S. Highest CCGs in region Newark & Sherwood CCG44M. Swale CCG34S. Knowsley CCG27N.