1. What is a “Deep Dive” pack? 1 CCGs have received a bespoke Commissioning for Value insights pack. These packs, sometimes referred to a Level 1 packs, analyse data on spend and outcomes at a Programme Budget level across a wide range of programmes. Those packs identified candidate programmes which offered the most value in return for improvement work – they answered the question of - where to look. Having selected one or more programmes to analyse in more detail – a Deep Dive pack would examine pathways in more detail to identify opportunities for improvements - What to change. The structure and content of Deep Dive packs has evolved through work done by Right Care and Yorkshire and Humber PHO (now PHE Knowledge and Intelligence Team) working CCGs in Derbyshire and Yorkshire and Humber. This anonymised example is taken from the work done by YHPHO. The structure of a pack is not fixed and immutable but it is based on a tried and tested successful approach. This exemplar will give you a tangible feel for what a Deep Dive pack would look like for your locality and your priority programmes. 1

2. Commissioning for Value Focus Pack CCG: XXX CCG Focus area: Cardiovascular pathway Draft Version 5.0 January 2013 2

3. Contents 1.Background and context – Aims of the packs – Packs as part of transformation process 2.Methodology – Analysis methods 3.Analysis – Summary messages – Analysis by pathway stage – Practice level variation – Secondary care quality – Bringing it all together 4.Next Steps 5.Annexes – Annex 1: Detailed indicator spine charts – Annex 2: CCG Benchmarks – Annex 3: Data sources – Annex 4: What works 3 Contents

4. Aim of the packs In September 2012, YHPHO produced Commissioning for Value Intelligence Packs for every CCG in Yorkshire and Humber. These packs identified programme areas which offered potential opportunities for improving outcome, quality and efficiency at local level. The packs included an offer to work with CCGs to develop this Focus Pack or ‘deep dive’ looking at an agreed programme area to understand variation across the pathway including GP practice benchmarking, working with local BI teams to identify opportunities for improvement together with the best evidence on what works. This work forms part of the health intelligence to support commissioning workstream which has been funded since 2009/10 by PCT Chief Executives in Y&H. In 2013/14 YHPHO’s specialist intelligence services will be part of the CSU business intelligence offer. Further support is available to use and explore the intelligence in this pack – contact sue.baughan@york.ac.uk or jake.abbas@york.ac.uk. sue.baughan@york.ac.ukjake.abbas@york.ac.uk Background 4

5. How these packs support service improvement 5 Background

6. Methodology used to produce this pack Analysed wide range of indicators from across the pathway focussing on spend and quality Analysed wide range of national benchmarked data to identify indicators where CCG is below the average for its cluster group Identified indicators where CCG is in worst quintile within its cluster Analysed practice based variation to identify practices which consistently compare poorly against their national clusters Identified key opportunities for value improvement and quantified potential impact Listed all the indicators where CGG is below average for cluster (see Annex) Quantified opportunity for indicators in bottom quintile from moving to average of top 40% for cluster Quantified additional financial opportunities for other indicators from moving to average of top 40% for cluster Quantification does not mean that the ‘saving’ or improvement can actually be made, but may however answer the question ‘Is it going to be worth focussing on this area?’ Reviewed national evidence base to identify potential interventions linked to opportunities Pulled together examples of ‘what works’ against ‘opportunity’ areas across the pathway Identified ‘high performing’ CCGs from cluster to support potential service/pathway review Methodology 6

7. Summary: Prevention and Prevalence 7 Summary Prevention 4/5 indicators are below the average of the top 40% benchmark group If the CCG reached the average of the top 40% in its benchmark group, 1,978 fewer people with a long term condition would smoke The CCG is in the highest quintile for binge drinking. This is based on a PCT modelled estimate from the Health Survey for England. If the estimate is correct then 20,161 fewer people would binge drink if the CCG reduced its rate to the benchmark average for the top 40%. The CCG may want to triangulate this with other indicators, for example alcohol related admissions Prevalence 9/10 indicators are above the average of the 40% benchmark group For CHD, stroke and hypertension the observed prevalence can be compared with that expected given the characteristics of XXX CCG’s population. For CHD the expected to observed ratio exceeds that of the 40% benchmark group. For stroke a further 83 cases and for hypertension a further 3,492 would need to be observed to achieve the expected to observed ratio of the 40% benchmark group.

8. Summary: Management in primary care 18/22 indicators are below the average of the top 40% benchmark group QOF indicators have been used but excepted patients have not been included in the denominator There are no indicators in the bottom quintile compared to the benchmark group There are three primary care management indicators where over 150 patients would benefit if the CCG moved to the average of the top 40% benchmark group – % CHD patients treated with a beta-blocker (182 more people) – % CHD patients who have had a flu immunisation (202 more people) – % hypertension patients with a record of BP <=150/90 (371 more people) £1.2 million reduced prescribing spend in primary care if CCG reduced to average of the 40% benchmark group 8 Summary

9. Summary: Management in secondary care and end of life care Management in secondary care 60/66 indicators are below the average in the top 40% benchmark group CVD, and within that classification, CHD and heart failure emergency admissions are all high (bottom quintile) compared to the benchmark group Although the rate of elective CHD admissions is relatively low, the cost of admission is relatively high (£270k more than average of top 40% benchmark group). LOS for CHD elective (280 bed days higher), stroke (over 3000 bed days higher) and angiography (over 1000 bed days higher) are all relatively high when compared to the average of the top 40% benchmark. End of life care An additional 78 people would die at home if the CCG rate matched that of the top 40% benchmark group 9 Summary

10. Number of Indicators (/of those looked at) where CCG below the average for the top two quintiles – (best 40% in its benchmark group) See Annex for full list Indicators in the bottom quintile v benchmark group - difference between NHS XXX CCG and the benchmark average of the top 40% in brackets, (p) – PCT based indicator Opportunity if NHS XXX CCG were to equal the benchmark average of the top 40% 4/5 Binge drinking (p) (11.8 % higher) Percentage of patients registered with a GP with a long term condition who smoke (4.4 % higher)  20,161 fewer people  1,978 fewer people 9/10 None  None 18/22 None  None Where does the CCG compare poorly against its benchmark group? Analysis by pathway stage (1) Prevention Prevalence / diagnosis Management in Primary Care 10

11. Number of Indicators (/of those looked at) where CCG below the average for the top two quintiles – (best 40% in its benchmark group) See Annex for full list Indicators in the bottom quintile v benchmark group -difference between NHS XXX CCG and the benchmark average of the top 40% in brackets, (p) – PCT based indicator Opportunity if NHS XXX CCG were to equal the benchmark average of the top 40% 60/66  CVD emergency admissions (DSR) (27.2% higher),  CHD emergency admissions (DSR) male (44.2% higher),  CHD emergency admissions (DSR) female (53.3% higher),  Heart failure emergency admissions (DSR) male (43.8% higher),  CHD: average cost per elective admission (female) (38.4% higher),  Non-elective Angioplasty procedures (DSR) males (48.9% higher),  CHD: average LOS per elective admissions (male) (83.1% higher),  Stroke: average LOS per emergency admissions (female) (90.2% higher),  Stroke: average LOS per emergency admissions (male) (112.4% higher),  Angiography: average LOS per procedure (101.8% higher),  Proportion of non-STEMI patients seen by member of cardiology team (p) (-12.3% lower),  Non elective spend (p) (52.1% higher),  Ambulance spend (p) (55.9% higher),  A&E spend (p) (69.7% higher)  381 fewer people  117 fewer people  66 fewer people  34 fewer people  £161k (total cost savings)  45 fewer procedures  202 bed days  1,693 bed days  1,695 bed days  1,089 bed days  12% of non-STEMI patients  £2.9M  £0.4M  £0.2M 2/2  None  None 1/1  Death at home or usual place of residence (p) (66.3 % higher)  78 more people Where does the CCG compare poorly against its benchmark group? Analysis by pathway stage (2) 11 \ \ Management in Secondary Care Social Care End of life Care 11

12. Where to focus: Understanding practice variation Practices have been compared against other practices within their practice cluster for all the indicators where data is available at practice level This information is presented here to form the basis of a discussion between the PHO, Business Intelligence in the CSU and the CCG about how further analysis could support practices in reducing unexplained practice variation The number of indicators where the practice is in the bottom quintile for the practice cluster has been compared on the next slide and the opportunities for the practices with the highest number of indicators in the bottom quintile has been quantified on the subsequent slide Practices will have less influence on management in secondary care than they do on management in primary care and this should be taken into account in the way CCGs interpret the information on practice variation 12 Analysis

13. Where to focus: Understanding practice variation 13 Analysis Number of CVD indicators in the bottom quintile of the practice cluster Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be inferred. The data are presented to identify potential areas of improvements rather than providing a definitive comparison of performance.

14. Where to focus: Top 3 GP practices with CVD indicators in the bottom quintile of the practice cluster and opportunities* in brackets 14 Analysis X PracticeY practiceZ practice Primary care % CHD BP <=150/90 (15), % CHD cholesterol <=5 mmol/l (10), % CHD patients aspirin, alternative anti- platelet therapy taken (7), % CHD treated with beta-blocker (11), % CHD influenza immunisation (15), % hypertension BP <=150/90 (40), % TIA/stroke BP <=150/90 (4), % TIA/stroke record of cholesterol (2), % TIA/stroke influenza immunisation (3), % stroke non-haemorrhagic, history of TIA, record anti-platelet agent (1), % HF confirmed echocardiogram (0), % CHD BP <=150/90 (19), % CHD aspirin, alternative anti-platelet therapy taken (9), % hypertension BP <=150/90 (82), % TIA/stroke BP <=150/90 (10), % TIA/stroke record of cholesterol (10), % HF patients confirmed echocardiogram (1), % AF treated with anti-coagulation drug therapy (3) % CHD cholesterol <=5 mmol/l (30), % CHD aspirin, alternative anti-platelet therapy taken (22), % CHD influenza immunisation (33), % history of MI treated with an ACE inhibitor (3), % hypertension record of BP (111), % hypertension BP <=150/90 (156), % of new stroke referred (7), % HF confirmed echocardiogram (2), % AF treated with anti-coagulation drug therapy (9) Secondary care CVD emergency admissions (70), CVD elective admissions (54), CHD emergency admissions (45), CVD elective admissions: LOS (21), CHD elective admissions: LOS (12), CVD: average cost per elective admission (£13.6k), CVD emergency admissions )weighted cost) (£33.8K), CVD elective admissions (weighted cost) (£70.9k) CVD emergency admissions (32), CHD emergency admissions (8), Stroke emergency admissions (4), HF emergency admissions (5), CVD elective admissions: LOS (40), CHD elective admissions: LOS (6), Stroke emergency admissions: LOS (284), Stroke: average cost per emergency admission (£19.9k), CVD emergency admissions (weighted cost) (£63.5k) CVD emergency admissions (25), CHD emergency admissions (10), HF emergency admissions (5), CHD elective admissions: LOS (26), CVD: average cost per elective admission (£30.7k), Stroke: average cost per emergency admission (£17.3k) * If they were to equal the practice cluster average Note, X practice does not have a practice cluster assigned to it and has been compared to the national average. Some of the secondary care opportunities calculated for this practice are greater than the number of original admissions due to small numbers and comparison to the national average.

15. Bringing it all together – Where to focus, what could work, who should we speak to Where to focusWhat could workWho should we speak to? * 15 Next step is to move from intelligence to action CCG needs to identify from the summary slides where to focus and what could work and which CCG may be an exemplar to follow This table illustrates this approach Annex 4 sets out more examples of ‘what works’ evidence included in the NHS Atlases of Variation Analysis

16. Other local intelligence to add in……… CCGs should consider what local intelligence is available to further triangulate with the intelligence in this pack. This may include: Practice variation analyses Up to date intelligence from secondary care Analysis from Acute Trust quality dashboard or other provider data Contract monitoring data Local prescribing data 16 Analysis

17. Annexes 17

18. Annex 1: Spine Charts 18 Minimum value in clusterMaximum value in cluster Key: Prevention Worse outcomeBetter outcome Prevalence Higher prevalence / Worse outcome Lower prevalence / Better outcome Annexes

19. Annex 1: Spine Charts 19 Worse outcome / Higher spend Primary Care Better outcome / Lower spend Annexes

20. Annex 1: Spine Charts 20 Secondary Care Worse outcome / Higher spend Better outcome / Lower spend Annexes

21. Annex 1: Spine Charts 21 Secondary Care continued Worse outcome / Higher spend Better outcome / Lower spend Annexes

22. Annex 1: Spine charts 22 Social care / End of Life Worse outcome / Higher spend Better outcome / Lower spend Annexes

23. Annex 2: Interim CCG cluster classification 23 NHS XXX CCG is in cluster 5. Annexes

24. Annex 3: Full indicator list 24 PathwayIndicatorData source PreventionSmoking (p)Modelled Estimates from Health Survey for England, 2006-08 Binge drinking (p)Modelled Estimates from Health Survey for England, 2007-08 Obesity (p)Modelled Estimates from Health Survey for England, 2006-08 Percentage of patients registered with a GP with a long term condition who smoke Quality and Outcomes Framework 2011/12 Four week quitters as a proportion of estimated adult smokers (p)Smoking cessation 2011/12 ONS Mid year population estimates 2010, Modelled Estimates from Health Survey for England, 2006-08 PrevalenceCHD prevalenceQuality and Outcomes Framework 2011/12 Stroke prevalenceQuality and Outcomes Framework 2011/12 Hypertension prevalenceQuality and Outcomes Framework 2011/12 Heart Failure prevalenceQuality and Outcomes Framework 2011/12 Heart failure due to LVD register prevalenceQuality and Outcomes Framework 2011/12 Atrial fibrillation prevalenceQuality and Outcomes Framework 2011/12 CVD prevention register prevalenceQuality and Outcomes Framework 2011/12 CHD expected to observed ratioModelled estimates of prevalence, Eastern Region Public Health Observatory, December 2011 Stroke expected to observed ratioModelled estimates of prevalence, Eastern Region Public Health Observatory, December 2011 Hypertension expected to observed ratioModelled estimates of prevalence, Eastern Region Public Health Observatory, December 2011 Primary care % CHD patients BP <=150/90Quality and Outcomes Framework 2011/12 % CHD patients cholesterol <=5 mmol/lQuality and Outcomes Framework 2011/12 % CHD patients aspirin, alt anti-platelet therapy or anti-coagulant takenQuality and Outcomes Framework 2011/12 % CHD patients treated with a beta-blockerQuality and Outcomes Framework 2011/12 % CHD patients influenza immunisationQuality and Outcomes Framework 2011/12 % of patients with history of MI treated with an ACE inhibitor, aspirin or etc Quality and Outcomes Framework 2011/12 % newly diagnosed patients with angina referred for specialist assessment Quality and Outcomes Framework 2011/12 % hypertension patients with a record of BPQuality and Outcomes Framework 2011/12 % hypertension patients BP <=150/90Quality and Outcomes Framework 2011/12 % TIA/stroke patients BP <=150/90Quality and Outcomes Framework 2011/12 % TIA/stroke patients with a record of cholesterolQuality and Outcomes Framework 2011/12 % of TIA/stroke patients cholesterol was <=5mmol/lQuality and Outcomes Framework 2011/12 Annexes

25. Annex 3: Full indicator list (continued) 25 PathwayIndicatorData source Primary Care % TIA/stroke patients influenza immunisationQuality and Outcomes Framework 2011/12 % stroke patients non-haemorrhagic with a record of anti-platelet agentQuality and Outcomes Framework 2011/12 % of new stroke/TIA patients referred for further investigationQuality and Outcomes Framework 2011/12 % HF patients confirmed by echocardiogram/specialist assessmentQuality and Outcomes Framework 2011/12 % HF patients due to LVD treated with ACE inhibitor/ARB no contraindicationQuality and Outcomes Framework 2011/12 % HF patients due to LVD treated with ACE inhibitor/ARB and beta- blockerQuality and Outcomes Framework 2011/12 % atrial fibrillation patients treated with anti-coagulation drug therapyQuality and Outcomes Framework 2011/12 % atrial fibrillation patients with ECG/specialist confirmed diagnosisQuality and Outcomes Framework 2011/12 Primary care spend (p)Programme Budgeting, 2010/11 Prescribing spend for circulationNHS Comparators, 2010/11 Secondary care CVD emergency admissions (DSR) Hospital Episode Statistics (HES) 2011/12, The NHS Information Centre for health and social care, ONS CVD elective admissions (DSR)HES 2011/12, The NHS Information Centre for health and social care, ONS CVD: average cost per emergency admissionHES 2011/12, The NHS Information Centre for health and social care, ONS CVD: average cost per elective admissionHES 2011/12, The NHS Information Centre for health and social care, ONS Cost of CVD emergency admissions (per head in weighted population)NHS Comparators, 2010/11 Cost of CVD elective admissions (per head in weighted population)NHS Comparators, 2010/11 CHD emergency admissions (DSR) maleHES 2011/12, The NHS Information Centre for health and social care, ONS CHD emergency admissions (DSR) femaleHES 2011/12, The NHS Information Centre for health and social care, ONS CHD elective admissions (DSR) maleHES 2011/12, The NHS Information Centre for health and social care, ONS CHD elective admissions (DSR) femaleHES 2011/12, The NHS Information Centre for health and social care, ONS Heart failure emergency admissions (DSR) maleHES 2011/12, The NHS Information Centre for health and social care, ONS Heart failure emergency admissions (DSR) femaleHES 2011/12, The NHS Information Centre for health and social care, ONS Stroke emergency admissions (DSR) maleHES 2011/12, The NHS Information Centre for health and social care, ONS Stroke emergency admissions (DSR) femaleHES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average cost per emergency admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average cost per emergency admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average cost per elective admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average cost per elective admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS Heart Failure: average cost per emergency admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS Heart Failure: average cost per emergency admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS Stroke: average cost per emergency admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS Stroke: average cost per emergency admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS Annexes

26. Annex 3: Full indicator list (continued) 26 PathwayIndicatorData source Secondary care Angiography procedures (DSR) malesHES 2011/12, The NHS Information Centre for health and social care, ONS Angiography procedures (DSR) femalesHES 2011/12, The NHS Information Centre for health and social care, ONS Angiography: average cost per procedureHES 2011/12, The NHS Information Centre for health and social care, ONS Non-elective Angioplasty procedures (DSR) malesHES 2011/12, The NHS Information Centre for health and social care, ONS Elective Angioplasty procedures (DSR) malesHES 2011/12, The NHS Information Centre for health and social care, ONS Non-elective Angioplasty procedures (DSR) femalesHES 2011/12, The NHS Information Centre for health and social care, ONS Elective Angioplasty procedures (DSR) femalesHES 2011/12, The NHS Information Centre for health and social care, ONS CABG procedures (DSR) malesHES 2011/12, The NHS Information Centre for health and social care, ONS CABG procedures (DSR) femalesHES 2011/12, The NHS Information Centre for health and social care, ONS Angioplasty: average cost per elective procedureHES 2011/12, The NHS Information Centre for health and social care, ONS Angioplasty: average cost per non-elective procedureHES 2011/12, The NHS Information Centre for health and social care, ONS CABG: average cost per procedureHES 2011/12, The NHS Information Centre for health and social care, ONS Total cardiac resynchronisation therapy device procedures (p) Cardiac Rhythm Audit, 2010 New pacemaker implant procedures (p) Cardiac Rhythm Audit, 2010 New implantable cardioverter-defibrillator procedures (p) Cardiac Rhythm Audit, 2010 Carotid endarterectomy procedures HES 2011/12, The NHS Information Centre for health and social care, ONS Carotid endarterectomy: average cost per procedure HES 2011/12, The NHS Information Centre for health and social care, ONS Valve procedures HES 2011/12, The NHS Information Centre for health and social care, ONS Valve: average cost per procedure HES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average LOS per emergency admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average LOS per emergency admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average LOS per elective admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS CHD: average LOS per elective admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS Stroke: average LOS per emergency admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS Stroke: average LOS per emergency admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS Heart Failure: average LOS per emergency admission (female)HES 2011/12, The NHS Information Centre for health and social care, ONS Heart Failure: average LOS per emergency admission (male)HES 2011/12, The NHS Information Centre for health and social care, ONS Angiography: average LOS per procedureHES 2011/12, The NHS Information Centre for health and social care, ONS Angioplasty: average LOS per procedureHES 2011/12, The NHS Information Centre for health and social care, ONS CABG: average LOS per procedureHES 2011/12, The NHS Information Centre for health and social care, ONS Valve: average LOS per procedureHES 2011/12, The NHS Information Centre for health and social care, ONS Carotid: average LOS per procedureHES 2011/12, The NHS Information Centre for health and social care, ONS Primary Angioplasty treatment time from calling for help (p)MINAP, 2010 Proportion of non-STEMI patients seen by member of cardiology team (p)MINAP, 2010 Annexes

27. Annex 3: Full indicator list (continued) 27 PathwayIndicatorData source Secondary care Percentage of 30 day mortality for STEMI cases (p)MINAP, 2010 TIA cases treated within 24 hours (p)Atlas 2.0 Stroke patients who spend 90% of their time on a stroke unit (p)Atlas 2.0 STEMI patients receiving primary angioplasty (p)Atlas 2.0 Elective and Daycase spend (p)Programme Budgeting, 2010/11 Non elective spend (p)Programme Budgeting, 2010/11 Outpatient spend (p)Programme Budgeting, 2010/11 Other secondary care spend (p)Programme Budgeting, 2010/11 Ambulance spend (p)Programme Budgeting, 2010/11 A&E spend (p)Programme Budgeting, 2010/11 Social care and End of life Percentage of stroke patients discharged to home or usual place of residenceHES 2011/12, The NHS Information Centre for health and social care, ONS Non health / social care spend per head (p)Programme Budgeting, 2010/11 Death at home or usual place of residence (p)PHO annual deaths extract, ONS Annexes