1. www.england.nhs.uk Support for Regional Medical Directors Challenging Variation Innovation Scorecard May 2016

2. www.england.nhs.uk 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 May 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.

3. www.england.nhs.uk3 Canagliflozin – Primary 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. 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 ? CCGs with low uptake RegionTrend North Tyneside CCG0N. Norwich CCG1,524M ↑ Newbury and District CCG8,493S ↑ CCGs with high uptake Oldham CCG2,019,671N ↑ South eastern Hampshire CCG1,243,930S ↑ Hammersmith and Fulham CCG1,186,219L ↑ Click here to see interactive heat map online 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

4. www.england.nhs.uk Dapagliflozin – Primary care Background This is one option for the treatment of type 2 diabetes recommended in NICE TA (TA288) published in October 2010, Dapagliflozin should be given with other drugs as a treatment for some 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 hereTA288here Key lines of enquiry Significant variation in uptake can be seen on the maps below. Is it being considered as a treatment option? 4 DDDs per 100,000 Resident population Click here to see interactive heat map online 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. CCGs with low uptake RegionTrend North Tyneside CCG242N ↑ Brighton and Hove CCG852S ↑ North Norfolk CCG901M ↑ CCGs with high uptake Medway CCG24,844S ↑ Lincolnshire East CCG21,636M ↑ Bolton CCG21,251N ↑

5. www.england.nhs.uk 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 ? 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. Click here to see interactive heat map online CCGs with low uptake RegionTrend Halton CCG0N. Nottingham West CCG0M. Tower Hamlets CCG0L. CCGs with high uptake Hastings and Rother CCG7,412S ↔ Bolton CCG1,405N ↓ Walsall CCG1,312M ↔

6. www.england.nhs.uk6 Empagliflozin – Primary care Background This is one option for treatment of type 2 diabetes recommended in NICE TA (TA336) published in March 2015 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.TA336 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 ? Click here to see interactive heat map online CCGs with low uptake RegionTrend West Lancashire CCG0N. Wandsworth CCG 0L. Surrey Heath CCG 0S. CCGs with high uptake Castle Point and Rochford CCG51,692M ↑ Bradford City CCG36,480N ↑ South Reading CCG27,145S ↑

7. www.england.nhs.uk 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. Click here to see interactive heat map online CCGs with low uptake RegionTrend Crawley CCG720S ↑ Islington CCG865L ↓ North Staffordshire CCG1,587M ↑ CCGs with high uptake Bradford City CCG20,291N ↔ Hastings and Rother CCG16,571S ↔ North Norfolk CCG10,693M ↔

8. www.england.nhs.uk8 Osteoporosis Group– Primary care Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have the area teams identified any local barriers to the use of this treatment in both primary care and secondary care ? DDD per 10,000 resident population age 50 and over 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 includes Alendronic Acid, Denosumab 60mg, Raloxifene Hydrochloride, Risedronate Sodium (excluding 30mg tablets), Strontium Ranelate and Teriparatide which have all been positively appraised by NICE TAs (TA 160, TA161,TA204) for use in primary and secondary prevention of fragility fractures in post-menopausal women with osteoporosis.TA 160, TA161 TA204 Click here to see interactive heat map online CCGs with low uptake RegionTrend Milton Keynes CCG17,573M ↔ Bassetlaw CCG20,853N ↔ Isle of Wight CCG24,532S ↔ CCGs with high uptake Wandsworth CCG60,218L ↔ Bath and North East Somerset CCG52,382S ↔ North Tyneside CCG51,928N ↔

9. www.england.nhs.uk9 Nalmefene – Primary care Background Nalmefene is recommended as a treatment option for alcohol dependence by NICE (TA325) since November 2014. 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 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. Click here to see interactive heat map online CCGs with low uptake RegionTrend Warrington CCG0N ↓ Wyre Forest CCG0M. West London (K&C & QPP) CCG 0L ↓ CCGs with high uptake Southport and Formby CCG407N ↑ Walsall CCG197M ↑ Central London (Westminster) CCG134L ↑

10. www.england.nhs.uk10 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 2014. 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. Click here to see interactive heat map online CCGs with low uptake RegionTrend Haringey CCG5,093L ↑ Thurrock CCG9,521M ↑ Slough CCG9,621S ↑ CCGs with high uptake Somerset CCG86,248S ↑ Scarborough and Ryedale CCG73,754N ↑ Dudley CCG66,003M ↑

11. www.england.nhs.uk11 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 2015. 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. Click here to see interactive heat map online CCGs with low uptake RegionTrend South Cheshire CCG0N. South Kent Coast CCG 0S. City and Hackney CCG 0L ↓ CCGs with high uptake North Durham CCG 871,72 3 N ↑ Portsmouth CCG 526,62 8 S ↑ Dudley CCG 508,55 1 M ↑

12. www.england.nhs.uk 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 ? 12 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. Click here to see interactive heat map online CCGs with low uptake RegionTrend Nottingham City CCG 178M ↓ Surrey Heath CCG 266S ↑ South Cheshire CCG 709N ↑ CCGs with high uptake Barnsley CCG15458 N ↔ Lincolnshire East CCG15261 M ↔ Kernow CCG9141 S ↔

13. www.england.nhs.uk Adalimumab – Secondary care Key lines of enquiry Have the local teams identified local barriers to the use of this treatment in secondary care ? Background NICE TAs: (TA146,TA187,TA195,TA199, TA375,TA383) published up to February 2016, recommended as a treatment option for psoriatic and rheumatoid arthritis, Crohn’s disease and ankylosing spondylitis, alongside other treatments.TA146 TA187TA195 TA199TA375 TA383 13 Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health). Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

14. www.england.nhs.uk14 Afatinib – Secondary care Background NICE TA: (TA310) published in April 2014 recommended as a possible treatment for adults with locally advanced or metastatic non-small-cell lung cancer.TA310 Key lines of enquiry Have the local teams identified any local barriers to the use of this treatment in secondary care ? Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved mgs per 100,000 Resident population

15. www.england.nhs.uk Boceprevir – Secondary care Background NICE TA: (TA253) published in April 2012, boceprevir with peginterferon alfa and ribavirin is recommended as an option for treatment for genotype 1 chronic hepatitis C in adults with the earlier stages of liver disease (known as compensated liver disease).TA253 Key lines of enquiry Have the local teams identified any local barriers to the use of this treatment in secondary care ? 15 Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

16. www.england.nhs.uk16 Dabrafenib – Secondary care Background NICE TA: (TA321) published in October 2014 recommended as a treatment option for people with melanoma that has spread, cant be removed by surgery and is BRAF V600 mutation-positive melanoma.TA321 Key lines of enquiry Have the local teams identified any local barriers to the use of this treatment in secondary care ? Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved mgs per 100,000 Resident population

17. www.england.nhs.uk Denosumab 70mg – Secondary care Background NICE TA: (TA265) published in October 2012 reommends Denosumab (70mgs) as a possible treatment for preventing complications that result from cancer spreading to the bone from solid tumours, except for prostate cancer, if the person would otherwise be prescribed a bisphosphonate for treating bone metastases from solid tumoursTA265 Key lines of enquiry Have the local teams identified any local barriers to the use of this treatment in secondary care? 17 Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved mgs per 100,000 Resident population

18. www.england.nhs.uk18 Enzalutamide– Secondary care Background NICE TA: (TA316) published in July 2014 recommends Enzalutamide as a possible treatment option for adults with metastatic hormone-relapsed prostate cancer, who have already had treatment with docetaxel-containing chemotherapy.TA316 Key lines of enquiry Have the local teams identified local barriers to the use of this treatment in both primary care and secondary care? Is this treatment option being considered? Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

19. www.england.nhs.uk19 Erythropoietin analogues-epoetin alpha, beta, zeta, darbepoetin alpha-Secondary care Background NICE TAs: (TA142,TA323) published in November 2011. Erythropoiesis-stimulating agents (epoetin alfa, beta, theta and zeta, and darbepoetin alfa) are recommended as possible treatments for anaemia in people having chemotherapy to treat cancer.TA142TA323 Key lines of enquiry Have the local teams identified local barriers to the use of these treatments in both primary care and secondary care? Is this being considered? Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

20. www.england.nhs.uk20 Golimumab – Secondary care Background NICE TA: (TA220,TA225,TA233,TA329) published up to February 2015 recommended for active and progressive psoriatic arthritis; severe ankylosing spondylitis(adults); rheumatoid arthritis that has responded inadequately to other disease-modifying anti-rheumatic drugs and active ulcerative colitis (moderate to severe) after failure of conventional therapy.TA220TA225TA233TA329 Key lines of enquiry Have the local teams identified any local barriers to the use of this treatment in secondary care? Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

21. www.england.nhs.uk21 Nalmefene – Secondary care Background Nalmefene is recommended as a treatment option for alcohol dependence by NICE (TA325) since November 2014. It is the topic of a NICE Implementation Collaborative work stream and further details can be found hereTA325here Key lines of enquiry Some areas do not appear to have access to this treatment. Have the local teams 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), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

22. www.england.nhs.uk Nilotinib – Secondary care Background NICE TA: (TA251) published in April 2012, Nilotinib is recommended as possible treatment for some people with chronic myeloid leukaemia.TA251 Key lines of enquiry Have the local teams identified any local barriers to the use of this treatment in secondary care ? 22 Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved mgs per 100,000 Resident population

23. www.england.nhs.uk Novel Oral Anti-Coagulants (NOACs) – Secondary 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 2014. 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 the 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 the local teams identified any local barriers to the use of this treatment in secondary care? 23 Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

24. www.england.nhs.uk Telaprevir – Secondary care Background NICE TA: (TA252) published in April 2012, Telaprevir with Peginterferon alfa and ribavirin is recommended as a possible treatment for genotype 1 chronic hepatitis C in adults with the earlier stages of liver disease (known as compensated liver disease).TA252 Key lines of enquiry Have the local teams identified any local barriers to the use of this treatment in secondary care ? 24 Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence. Q2 2015-16 Re-used with the permission of the Health and Social Care Information Centre. All rights reserved DDDs per 100,000 Resident population

25. www.england.nhs.uk Cardiac Combined (TA314) Medical Technology Background Cardiac resynchronisation therapy for the treatment of heart failure has been updated and replaced by NICE TA (TA314)TA (TA314) Key lines of enquiry Have CCGs and regional teams identified any local barriers to the use of this medical technology ? Procedures per 100k resident population, by CCGs Sources: Procedure - (HES), Population - (ONS) Note: data have not been adjusted for demography & disease prevalence 25 Click here to see interactive heat map online CCGs with low usage RegionTrend Surrey Heath CCG0S ↓ Nottingham West CCG0M ↓ Bradford City CCG0N ↓ CCGs with high usage Fylde & Wyre CCG28N ↑ Kernow CCG18S ↑ Birmingham South and Central CCG14M ↔

26. www.england.nhs.uk26 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 CCGs with low usage Ratio of coloscopy to flexible sigmoidoscopy RegionTrend Corby CCG0M. Southport and Formby CCG1N. Portsmouth CCG1S. CCGs with high usage Doncaster CCG10N. North Hampshire CCG4S. Bromley CCG4L.

27. www.england.nhs.uk Rate of computed tomography (CT) colonoscopy procedures per population by CCG 27 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. CCGs with low usage RegionTrend Newcastle North and East CCG0N. Swindon CCG0S. Wolverhampton CCG 0M. CCGs with high usage 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

28. www.england.nhs.uk Rate of dual-energy X-ray absorptiometry (DEXA) activity per weighted population by CCG 28 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 ? CCGs with low usage RegionTrend Isle of Wight CCG90S ↓ Corby CCG232S ↑ Bolton CCG478N ↑ CCGs with high usage 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

29. www.england.nhs.uk Proportion of prevalent dialysis population on home based modalities (Home HD and PD) by CCG 29 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. CCGs with low usage RegionTrend Bradford City CCG2N. Hammersmith and Fulham CCG4L. Aylesbury Vale CCG7S. CCGs with high usage Newark & Sherwood CCG44M. Swale CCG34S. Knowsley CCG27N. Click here to see interactive heat map online Percentage of people receiving treatment at home