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

2. 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.

3. 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

4. National Ambitions for High Blood Pressure

5. 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

6. Detection and Diagnosis of High Blood Pressure in South Cheshire CCG

7. How much hypertension is diagnosed? (C&M CCGs compared)
Source:

8. What proportion of actual high BP is known?

9. 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

10. BP checks in last 5 years (C&M CCGs compared) Good coverage of BP testing but diagnosis gap remains - Why?

11. 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

12. 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.

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

14. 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

15. BP control to QoF target (C&M CCGs compared)

16. BP Control: Comparing South Cheshire with 10 similar CCGs

17. % 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

18. 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.

19. Primary care prescribing: High blood pressure and cholesterol medications

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

21. South Cheshire Primary Care Prescribing Spend: CHD

22. South Cheshire Primary Care Prescribing Spend: Stroke

23. Statin prescribing for high CVD risk BP patients (C&M CCGs compared)

24. 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

25. On Patients On Services
Impacts of High BP
On Patients On Services

26. The National Cost of High Blood Pressure
Graphic -
Complications include:
Coronary Heart Disease
Abnormal heart rhythms and stroke
Chronic Kidney Disease
Vascular dementia

27. Coronary Heart Disease Prevalence

28. Coronary Heart Disease Admission Rate (C&M CCGs compared)

29. CHD Inpatient Spend and Bed Days

30. CHD Premature Mortality Rate (C&M CCGs compared)

31. Atrial Fibrillation (AF) Prevalence

32. Inpatient Bed Days for Abnormal Heart Rhythm

33. Stroke Prevalence

34. Stroke admission rates (C&M CCGs compared)

35. Stroke spend and bed days

36. Premature stroke mortality (C&M CCGs compared)

37. Chronic Kidney Disease Prevalence

38. Dementia Prevalence

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

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

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

42. Adult obesity prevalence

43. Adult Smoking Prevalence (compared with C&M CCGs)

44. Adult Smoking Prevalence

45. Alcohol-specific admissions

46. Physically inactive adults

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

48. 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%)

49. 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