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Commissioning for Value Focus Pack

CCG: Heywood, Middleton & Rochdale

Focus Area : Respiratory Programme Budget Category

1

What is a “Deep Dive” pack?

CCGs have received a bespoke Commissioning for Value insights pack. These packs, sometimes referred to as 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. Deep Dive packs further examine areas chosen by the CCGs in order to gain a deeper understanding of issues within specific programmes of work or clinical pathways - 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 with CCGs in Derbyshire and Yorkshire and Humber. The packs are produced by GEM CSU analysts working with consultants in public health medicine from Solutions for Public Health (an NHS enterprise hosted by GEM CSU).

2

Contents

1. Background and context

• Aims of the packs

• Packs as part of transformation process

2. Methodology

• Analysis methods

• CCG Benchmarking and Opportunities

3. CCG Analysis

• Respiratory – the context for the deep dive analysis

• Summary messages for pathway stages:

Prevalence

Management in Primary Care

Management in Secondary Care

Mortality

• Opportunity table for indicators in the bottom quintile of benchmark group

4. Where to focus: Understanding practice variation

All Practices: Indicators in the bottom quintile

Top 3 Practices: Opportunities table

5. Bringing it all together, National Guidance

Annexes

• Annex 1 – Spine charts and opportunity tables

• Annex 2 – CCG Cluster Classification

• Annex 3 – Practice Cluster Classification

• Annex 4 – Indicator List

• Glossary

3

The Commissioning for Value phase one packs, produced by NHSE, PHE and NHS Right

Care, included an offer to work with CCGs to develop this Focus Pack, or ‘deep dive’.

The deep dive looks at an agreed programme area to understand variation across the

pathway, including GP practice benchmarking. Working with local intelligence teams, the

deep dive will look to identify opportunities for improvement and support the CCG's

discussion on methods of improving clinical pathways.

Further support is available to use and explore the intelligence in this pack

Aims of the Packs


4

How these Packs Support Service Improvement

NHSE GEM


5

Analysed wide range of indicators from across the pathway focussing on risk factors, spend, primary and secondary care usage and quality

• Analysed wide range of national benchmarked data to identify indicators where CCG is below the average for its CCG cluster group (see Annex 2)

• Identified indicators where CCG is in worst quintile within its cluster group

• Analysed practice based variation to identify practices which consistently compare poorly against their national clusters

Identified opportunities for value improvement and quantified potential impact

• Listed all the indicators where CGG is below average for CCG cluster

• Quantified opportunity for indicators in bottom quintile moving to the CCG Cluster average

• Quantified additional opportunities for indicators moving to the top 20% for the CCG 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

2. Methodology – Analysis Methods

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2. Methodology – CCG Benchmarking and Opportunities

• CCGs are compared using a benchmark cluster group of most similar

CCGs in terms of age, ethnicity, deprivation and population density

• The benchmark cluster group is based on YHPHO CCG classification

methodology and differs to those used in the phase 1 packs. The

definitions and constituent CCGs are in Annex 2

• Indicators are ranked out of 100 within the CCG benchmark group. A

rank of ‘1’ is taken as comparatively ‘worse’ e.g. higher spend/higher

prevalence/ higher admission rate/lower screening uptake/lower urgent

referrals

• Indicators where the CCG is in the ‘bottom quintile’ of the benchmark

group (ranked 1-20) are highlighted in the summary analysis slides and

summary opportunity table

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• An ‘opportunity’ is calculated based on the CCG reaching the

benchmark group average, and also reaching the 80th percentile value,

i.e. the ‘best performing’ quintile, of the benchmark group

• 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?’

• Spine graphs and the full opportunity tables are in Annex 1

• A list of all indicators used is in Annex 4

• A Glossary is available

2. Methodology – CCG Benchmarking and Opportunities

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Deep Dive Pack Phase 1

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The Right Care Commissioning for Value phase 1 pack highlighted that, compared to their comparator CCGs, Heywood, Middleton & Rochdale CCG had:

• Significantly higher prevalence of asthma

• COPD prevalence in the highest quartile in England

• Significantly higher spend on prescribing

• Significantly higher respiratory admission rates across all secondary

care, and non-elective care

• Significantly higher emergency admissions relative to patients on the

register

3. Respiratory – Context for Deep Dive Analysis

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DDP Phase 1 vs DDP Phase 2 analysis

DDP Phase 2 Differs from DDP Phase 1 analysis

• Different clustering methods

• nearest 10 CCGs vs colour coded-cluster CCGs

• Phase 1, but not phase 2 method included

population size as a clustering metric

• Different years of data

• 2011/12 vs 2012/13 for phase 2

Therefore analysis gives different results

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DDP1 Analysis based on

comparison with 10 most similar

CCGs

• NHS Bolton CCG

• NHS Oldham CCG

• NHS Bradford Districts CCG

• NHS Stoke on Trent CCG

• NHS South Tees CCG

• NHS Bury CCG

• NHS Tameside and Glossop CCG

• NHS Newcastle West CCG

•NHS Leeds South and East CCG

• NHS Walsall CCG

16

DDP 2 Analysis based on

comparison with all CCGs in

yellow cluster group

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Heywood, Middleton & Rochdale CCG is in the Yellow Cluster Group: A younger population with a higher

than average proportion of the population from Black and Asian ethnic groups and moderate levels of

deprivation.

Code CCG Name Code CCG Name00G NHS Newcastle North and East CCG 06P NHS Luton CCG00H NHS Newcastle West CCG 07L NHS Barking and Dagenham CCG00Q NHS Blackburn with Darwen CCG 07M NHS Barnet CCG00Y NHS Oldham CCG 07V NHS Croydon CCG01D NHS Heywood, Middleton and Rochdale CCG 07W NHS Ealing CCG01G NHS Salford CCG 07X NHS Enfield CCG01M NHS North Manchester CCG 07Y NHS Hounslow CCG01N NHS South Manchester CCG 08A NHS Greenwich CCG02R NHS Bradford Districts CCG 08E NHS Harrow CCG03C NHS Leeds West CCG 08G NHS Hillingdon CCG03F NHS Hull CCG 08J NHS Kingston CCG03G NHS Leeds South and East CCG 08N NHS Redbridge CCG03J NHS North Kirklees CCG 08R NHS Merton CCG03N NHS Sheffield CCG 09H NHS Crawley CCG04C NHS Leicester City CCG 10R NHS Portsmouth CCG04F NHS Milton Keynes CCG 10T NHS Slough CCG04K NHS Nottingham City CCG 10W NHS South Reading CCG04X NHS Birmingham South and Central CCG 10X NHS Southampton CCG05A NHS Coventry and Rugby CCG 11H NHS Bristol CCG05L NHS Sandwell and West Birmingham CCG 13P NHS Birmingham Crosscity CCG05Y NHS Walsall CCG 99A NHS Liverpool CCG06A NHS Wolverhampton CCG

Annex 2: CCG cluster classification

Cluster Classification Group

0-19

years

20-39

years

40-59

years

60-79

years

80+

years

Population

from Black

ethnic

groups

Population

from Asian

ethnic

groups

Population

density

(persons

per hectare)

Average

IMD

2010

score

Purple An older population living in rural areas

and low deprivation levels 22.3% 22.0% 27.8% 21.9% 6.0% 0.5% 1.9% 1.9 16.85

Blue

A very young population with a high

proprtion of the population from Black and

Asian ethnic groups and high levels of

deprivation.

26.4% 41.1% 21.3% 9.0% 2.1% 16.2% 31.6% 80.4 40.78

Green

A younger population with a high

proportion of the population from Black

and Asian ethnic groups and moderate

levels of deprivation.

21.6% 42.0% 23.5% 10.4% 2.5% 16.7% 10.3% 100.1 28.81

Yellow

A younger population with a higher

than average proportion of the

population from Black and Asian

ethnic groups and moderate levels of

deprivation.

26.0% 31.6% 24.5% 14.1% 3.7% 6.7% 17.7% 26.2 29.00

Orange

A population with an average age

structure, average deprivation levels and

a low population density. 24.2% 25.3% 27.9% 18.2% 4.5% 1.5% 4.6% 5.1 20.38

The CCG Cluster groups are taken from YHPHO methodology, which groups together CCGs with similar populations. It is

based on statistical cluster analysis (K-means analysis) including variables of age structure of the population, the population

from Black and Asian ethnic groups, population density and deprivation.

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Deep Dive Phase 2

19

CCG Indicators and Opportunities in the bottom

quintile of the benchmark cluster group

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3. ANALYSIS

Gain if CCG had same 'rate' as

benchmark cluster of CCGs

Benchmark average

Percentage of patients registered with a GP aged 15+ recorded as current smoker 24.50% 21.10% 6096 fewer smokers

QOF COPD prevalence 2.30% 1.70% 1439 fewer COPD cases

QOF Asthma prevalence 6.90% 5.70% 2518 fewer asthma cases

Respiratory Cost prescribed per 1000 population £24,590 £19,164 £1536312 reduction

Respiratory Items prescribed per 1000 population 1683.5536 1282.757478 89915 fewer items prescribed

Inhaled Corticosteroids ADQ per STAR PU Cost £0.60 £0.50 £381442 reduction

COPD Cost prescribed per 1000 population £7,382 £5,097 £589652 reduction

COPD Items prescribed per 1000 population 353.3 251.1 24952 fewer items prescribed

% with COPD who have had a review including assessment of breathlessness in last 15 months (COPD13) 88.80% 90.90% 101 additional patients managed

Asthma Cost prescribed per 1000 population £15,619 £12,014 £855836 reduction

Asthma Items prescribed per 1000 population 874.66724 646.1322258 56207 fewer items prescribed

Other Respiratory Cost prescribed per 1000 population £2,383 £1,938 £120193 reduction

Other Respiratory Items prescribed per 1000 population 546.31832 393.2738719 39474 fewer items prescribed

Prevalence

Primary Care

Pathway step IndicatorCCG

Value

Benchmark

Value

CCG Indicators and Opportunities in the bottom

quintile of the benchmark cluster group

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3. ANALYSIS

Gain if CCG had same 'rate' as

benchmark cluster of CCGs

Benchmark average

Respiratory Inpatient spend per 1000 population £2,891 £2,127 £170505 reduction

Respiratory Secondary care admissions per 1000 population 25.7 19.3 1410 fewer admissions

Respiratory Inpatient admissions per 1000 population 2.0 1.5 121 fewer admissions

Respiratory Emergency admissions per 1000 population 21.6 15.4 1352 fewer admissions

Under 75 years Emergency Respiratory Admissions DSR per 100,000 3217.9 2072.7 2387 fewer admissions

Asthma Secondary care spend per 1000 population £2,005 £1,299 £159105 reduction

Asthma Emergency spend per 1000 population £1,775 £1,208 £127738 reduction

Asthma Secondary care admissions per 1000 population 2.3 1.4 206 fewer admissions

Asthma Emergency admissions per 1000 population 2.1 1.3 170 fewer admissions

Asthma Secondary care admissions per Asthma register 3.5 2.5 145 fewer admissions

Other Respiratory Inpatient spend per 1000 population £2,703 £2,028 £150817 reduction

Other Respiratory Secondary care admissions per 1000 population 19.9 15.2 1022 fewer admissions

Other Respiratory Inpatient admissions per 1000 population 2.0 1.5 112 fewer admissions

Other Respiratory Emergency admissions per 1000 population 16.1 11.5 1002 fewer admissions

Emergency admissions for children with lower respiratory disease 684.5 418.6 144 fewer admissions

Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000 931.1 430.8 1115 fewer admissions

Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000 966.6 445.4 1086 fewer admissions

Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000 801.2 510.0 649 fewer admissions

Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000 741.2 447.6 612 fewer admissions

Secondary Care All

Respiratory

Secondary Care All

Asthma

Secondary Care

Other Respiratory

Pathway step IndicatorCCG

Value

Benchmark

Value

3 / 6 indicators for prevalence are in the bottom quintile of the benchmark group:

1. Percentage of patients registered with a GP aged 15+ recorded as current smoker

2. QOF COPD prevalence

3. QOF Asthma prevalence

Summary: Prevalence

3. ANALYSIS

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10 / 35 indicators are in the bottom quintile of the benchmark group

Prescribing:

1. Respiratory Cost prescribed per 1000 population

2. Respiratory Items prescribed per 1000 population

3. Inhaled Corticosteroids ADQ per STAR PU Cost

4. COPD Cost prescribed per 1000 population

5. COPD Items prescribed per 1000 population

6. Asthma Cost prescribed per 1000 population

7. Asthma Items prescribed per 1000 population

8. Other Respiratory Cost prescribed per 1000 population

9. Other Respiratory Items prescribed per 1000 population

Summary: Management in Primary Care

3. ANALYSIS

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10 / 35 indicators are in the bottom quintile of the benchmark group

QOF

10.% with COPD who have had a review including assessment of

breathlessness in last 15 months (COPD13)

Summary: Management in Primary Care

3. ANALYSIS

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19 / 50 indicators are in the bottom quintile of the benchmark group.

Respiratory admissions (elective, non-elective) and inpatient spend

1. Respiratory Inpatient spend per 1000 population

2. Respiratory Secondary care admissions per 1000 population

3. Respiratory Inpatient admissions per 1000 population

4. Respiratory Emergency admissions per 1000 population

5. Under 75 years Emergency Respiratory Admissions DSR per 100,000

Summary: Management in secondary care

3. ANALYSIS

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Admissions (elective, non-elective) and spend for asthma

6. Asthma Secondary care spend per 1000 population

7. Asthma Emergency spend per 1000 population

8. Asthma Secondary care admissions per 1000 population

9. Asthma Emergency admissions per 1000 population

10.Asthma Secondary care admissions per Asthma register


3. ANALYSIS

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Other Respiratory admissions (elective, non-elective) and spend

11.Other Respiratory Inpatient spend per 1000 population

12.Other Respiratory Secondary care admissions per 1000 population

13.Other Respiratory Inpatient admissions per 1000 population

14.Other Respiratory Emergency admissions per 1000 population


3. ANALYSIS

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Emergency admissions for upper and lower RT infections and for children

with lower respiratory disease

15.Emergency admissions for children with lower respiratory disease

16.Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000

17.Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000

18.Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000

19.Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000


3. ANALYSIS

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0 / 3 indicators are in the bottom quintile of the benchmark group:

Summary: Mortality

3. ANALYSIS

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Respiratory Prevalence

30


The analysis showed HMR CCG in the bottom quintile of cluster CCGs

for estimates of COPD and asthma prevalence in the registered

population, as well as adult (>15 years of age) smoking prevalence

31


•Recorded smoking status in the registered population provides an

estimate of the adult population smoking prevalence

•Smoking prevalence can be reduced by tobacco control which

includes smoking cessation services

•The effectiveness of tobacco control and smoking cessation services

can be evaluated using indicators such as smoking prevalence in the

registered population

•Higher estimates of smoking prevalence suggests comparatively

higher unmet need and an opportunity to offer smoking cessation

interventions to more smokers

•Primary and secondary care services offer opportunities to reduce

smoking prevalence, maximise the number of people who quit smoking

thereby reducing smoking related morbidity and mortality

Hypothesis: smoking prevalence

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•The relatively higher smoking prevalence in the HMR CCG registered population may reflect relative under-provision and/or lower uptake of smoking cessation services

•Alternative explanations include:

• Better recording of smoking status

• Subgroup(s) of the population with significantly higher smoking rates than would be expected from the known sociodemographic characteristics of the population

• High provision and uptake of smoking cessation services but issues concerning the wider programme of tobacco control

• Higher prevalence rate may be due to chance/random variation/usual cause variation – no CIs or statistical tests have been performed

Smoking prevalence: Explanations to consider


33

Respiratory prevalence

Hypothesis: asthma prevalence

o Asthma prevalence in the lower quintile of CCGs reflects higher asthma

prevalence in the population

o To be on the asthma register, patients need a diagnosis of asthma and a

prescription for an asthma drug within the year

o Higher prevalence may reflect CCG population more at risk eg LBW babies,

maternal smoking and secondary exposure of tobacco smoke in children,

environmental and occupational exposure to allergens

o Investment in programmes aiming to decrease the at risk population eg high

quality tobacco control programmes and high quality smoking cessation

services, may reduce population exposure to triggers and thereby reduce the

number of asthma episodes managed by respiratory services in both primary

and secondary care

o Higher asthma prevalence may therefore reflect the need to target action to

further reduce the at risk population

34


Other explanations to be considered

•Asthma is not preventable therefore estimates of asthma prevalence

cannot be used to evaluate effectiveness of primary prevention

interventions. Interventions are aimed at improving control of asthma

and prevention of asthma attacks.

•Asthma is under-diagnosed due to a combination of patients not

presenting and clinicians not diagnosing /misdiagnosing

• ?higher prevalence rate may reflect better case ascertainment -

desirable

• ?higher prevalence rate may reflect more misdiagnosis and/or

poorer quality assessment with spirometry - undesirable

•?higher prevalence rate may be due to chance/random variation/usual

cause variation – no CIs or statistical tests have been performed

35


Hypothesis: COPD Prevalence

•Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease

•The main cause of COPD is smoking

•Estimated COPD prevalence in the registered population is a marker of historic smoking patterns, as the development of COPD is related to the level of tobacco exposure over time, usually years

•Higher prevalence of COPD reflects higher need for

• Primary prevention (tobacco control) and smoking cessation (to prevent disease progression)

• High quality health care services (primary and secondary care, pulmonary rehab) as defined by QOF and NICE

36


COPD Prevalence: Explanations to consider

•COPD is under-diagnosed due to a combination of patients not

presenting and clinicians not diagnosing /misdiagnosing

• ?higher prevalence rate may reflect better case ascertainment -

desirable

• ?higher prevalence rate may reflect more misdiagnosis and/or

poorer quality assessment with spirometry - undesirable

•?higher prevalence rate may be due to chance/random variation/usual

cause variation – no CIs or statistical tests have been performed

37

Respiratory primary care

38


Analysis showed HMR CCG to be in the lower quintile of

cluster CCGs for:

• 9 Prescribing indicators

• 1 QOF indicator - % with COPD who have had a review

including assessment of breathlessness in last 15 months

(COPD13)

39

Respiratory prescribing

Prescribing: Hypothesis

o Examination of the variation in prescribing costs and items

prescribed can be useful in identifying potentially

inappropriate prescribing

o High prescribing costs may point to the need for better

medicines optimisation and better medicines management

both of which support better and more cost-effective

prescribing in primary care

o Optimisation of prescribing

• reduces hospital admissions and associated costs

• helps patients better manage their care with consequent

improvement in health outcomes

• may reduce prescribing costs

40


9 indicators are in the bottom quintile of the benchmark group:

•Respiratory Cost prescribed per 1000 population

•Respiratory Items prescribed per 1000 population

•Inhaled Corticosteroids ADQ per STAR PU Cost

•COPD Cost prescribed per 1000 population

•COPD Items prescribed per 1000 population

•Asthma Cost prescribed per 1000 population

•Asthma Items prescribed per 1000 population

•Other Respiratory Cost prescribed per 1000 population

•Other Respiratory Items prescribed per 1000 population

If the CCG had the same rate of spend on respiratory drugs as the cluster average, potential savings could reach£1.5m reduction in respiratory prescribing spend

41


The bulk of the prescribing

data covers the following

classes of drugs, most of

which are prescribed in

primary care rather than

secondary care:

• Bronchodilators

• Corticosteroids

• Cromoglicate and related therapy and leukotriene receptor antagonists

• Antihistamines, hyposensitisation, and allergic emergencies

• Respiratory stimulants and pulmonary surfactant

• Oxygen

• Mucolytics

• Aromatic inhalations

• Cough preparations

• Systemic nasal decongestants

42


Explanations to consider:

• Prescribing may be appropriate and commensurate with

need ie. high prevalence of asthma and COPD

• Prescribing is suboptimal and requires investigation

• An audit of drugs used in the management of asthma

and COPD could help in the initial investigation of

potentially inappropriate prescribing

• Heads of medicines management could lead

medicine optimisation initiatives to improve healthcare

utilisation, outcomes and reduce spend

43

Respiratory: Management of Asthma and COPD

44


services

The analysis shows the CCG to be in the bottom quintile for

one of the COPD QOF indicators - suggesting that a lower

proportion of patients with COPD are recorded as

benefiting from clinical review with assessment of

breathlessness (every 15 months)

45

Defining high quality primary care in respiratory

disease QOF indicators for smoking, COPD and Asthma

NICE guidance and quality standards for COPD and

Asthma

46

Smoking QOF standards

o Patients with LTCs should have their smoking status

assessed and recorded in their notes within the preceding 15

months

o Patients with LTCs who smoke should be offered smoking

cessation advice or referral to a specialist service, where

available, within the preceding 15 months

o Patients aged 15 years and over should have their

smoking status assessed and recorded in their notes

within the preceding 27 months

o Patients aged 15 years and over who are recorded as

current smokers should be offered support and treatment

within the preceding 27 months

47

High quality COPD care QOF

o The practice produces a register of patients with COPD

o Patients with COPD have a review, undertaken by a

healthcare professional, including an assessment of

breathlessness using the MRC dyspnoea score in

the preceding 15 months

o Patients with COPD are assessed with spirometry and

their FEV1 is recorded within the preceding 15 months.

o Patients with COPD have their diagnosis confirmed by

post bronchodilator spirometry

o Patients with COPD have influenza immunisation in the

preceding 1 September to 31 March

48

High quality asthma care QOF

o The practice can produce a register of patients with asthma,

excluding patients with asthma who have been prescribed no

asthma-related drugs in the preceding 12 months

o Patients aged 8 years and over diagnosed as having asthma have

measures of variability or reversibility recorded

o Patients with asthma who have an asthma review within the

preceding 15 months that includes an assessment of asthma

control using the 3 RCP questions

o Patients with asthma between the ages of 14 and 19 years have

their smoking status assessed and recorded within the preceding 15

months

49

Asthma quality standards NICE

The elements of good care are specified in NICE guidance and quality

standards. High quality asthma care has the following features:

1. People with newly diagnosed asthma are diagnosed in accordance

with BTS/SIGN guidance

2. Adults with new onset asthma are assessed for occupational

causes.

3. People with asthma receive a written personalised action plan

4. People with asthma are given specific training and assessment in

inhaler technique before starting any new inhaler treatment

5. People with asthma receive a structured review at least annually

6. People with asthma who present with respiratory symptoms receive

an assessment of their asthma control.

50

Asthma quality standards NICE

7. People with asthma who present with an exacerbation of their symptoms

receive an objective measurement of severity at the time of presentation

8. People aged 5 years or older presenting to a healthcare professional with

a severe or life-threatening acute exacerbation of asthma receive oral or

intravenous steroids within 1 hour of presentation

9. People admitted to hospital with an acute exacerbation of asthma have a

structured review by a member of a specialist respiratory team before

discharge

10. People who received treatment in hospital or through out-of-hours

services for an acute exacerbation of asthma are followed up by their own

GP practice within 2 working days of treatment

11. People with difficult asthma are offered an assessment by a

multidisciplinary difficult asthma service

51

COPD quality standards NICE

The elements of good care are specified in NICE guidance and quality

standards. High quality COPD care has the following features:

1.People with COPD have one or more indicative symptoms recorded, and have the

diagnosis confirmed by post-bronchodilator spirometry carried out on calibrated

equipment by healthcare professionals competent in its performance and

interpretation.

2.People with COPD have a current individualised comprehensive management plan,

which includes high-quality information and educational material about the condition

and its management, relevant to the stage of disease.

3.People with COPD are offered inhaled and oral therapies, in accordance with NICE

guidance, as part of an individualised comprehensive management plan.

4.People with COPD have a comprehensive clinical and psychosocial

assessment, at least once a year or more frequently if indicated, which includes

degree of breathlessness, frequency of exacerbations, validated measures of

health status and prognosis, presence of hypoxaemia and comorbidities.

52


5.People with COPD who smoke are regularly encouraged to stop and are

offered the full range of evidence-based smoking cessation support.

6.People with COPD meeting appropriate criteria are offered an effective,

timely and accessible multidisciplinary pulmonary rehabilitation programme.

7.People who have had an exacerbation of COPD are provided with

individualised written advice on early recognition of future exacerbations,

management strategies (including appropriate provision of antibiotics and

corticosteroids for self-treatment at home) and a named contact.

8.People with COPD potentially requiring long-term oxygen therapy are

assessed in accordance with NICE guidance by a specialist oxygen service.

53


9.People with COPD receiving long-term oxygen therapy are reviewed in accordance with

NICE guidance, at least annually, by a specialist oxygen service as part of the integrated

clinical management of their COPD.

10.People admitted to hospital with an exacerbation of COPD are cared for by a respiratory

team, and have access to a specialist early supported-discharge scheme with appropriate

community support.

11.People admitted to hospital with an exacerbation of COPD and with persistent acidotic

ventilatory failure are promptly assessed for, and receive, non-invasive ventilation delivered by

appropriately trained staff in a dedicated setting.

12.People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of

discharge.

13.People with advanced COPD, and their carers, are identified and offered palliative care that

addresses physical, social and emotional needs.

54


Explanations to be considered:

• Is the annual assessment of COPD patients systematic

in the assessment of breathlessness using the MRC

dyspnoea score?

55

Respiratory Secondary Care

56

Respiratory secondary care

Hypothesis:

o Asthma and COPD are ambulatory care sensitive

conditions

o Ambulatory care sensitive (ACS) conditions are chronic

conditions for which it is possible to prevent acute

exacerbations and reduce the need for hospital admission

through active management, such as vaccination; better

self-management, disease management or case

management; or lifestyle interventions

o Most asthma and COPD is managed in primary care but

effective control requires multidisciplinary teams working

across both primary and secondary care

57


Hypothesis

o Despite hospital admission for asthma and COPD being largely

preventable, a significant proportion of all acute hospital activity is

related to asthma and COPD.

o Variation in admission rates is likely to reflect variation in how

effectively asthma and COPD are managed particularly in primary

care

o Admissions for respiratory tract infections such as influenza and

pneumonia are also preventable through effective vaccination in at

risk subgroups of the population and high quality primary care

management of RTIs

o These avoidable admissions are costly and offer the opportunity

for significant financial savings

58


Evidence based interventions for reducing spend and improving

outcomes in ACS conditions:

• Purdy S (2010). Avoiding Hospital Admissions. What does the

research evidence say? London: The King’s Fund.

• NICE clinical guideline and Quality standards for COPD

• British Thoracic Society and Scottish Intercollegiate Guidelines

Network clinical guideline 101 (2008, updated 2011) and NICE

Quality standards for asthma

59


Indicators are in the bottom quintile of the

benchmark group include those for:

• Hospital admissions (all, emergency) for all

respiratory conditions including ambulatory care

sensitive conditions – asthma and respiratory

tract infections (including influenza and

pneumonia)

• Respiratory spend (all, emergency)

60


o The analysis suggests that there is scope for improving the management of ambulatory care sensitive conditions thereby reducing avoidable admissions and spend

o If HMR CCG reduced its hospital admission rates (all, emergency) and spend for respiratory disease to that of the cluster average, then potential savings

• £564K reduction in respiratory spend across secondary care

• £159K reduction in asthma spend across secondary care

• £314k reduction in other respiratory emergency spend

• 1115 fewer emergency admissions for upper respiratory infections and 649 fewer emergency admissions for lower respiratory infections

61

0 / 3 indicators are in the bottom quintile of the benchmark group:

Summary: Mortality

3. ANALYSIS

62

• Practices are compared using a benchmark cluster group of the most similar

practices in terms of age, ethnicity, deprivation and population density. The

practice cluster group definitions and constituent practices are in Annex 3.

Practices are compared 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 CCG, the CSU and Public Health 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


63

Number of Respiratory 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.

The chart on the following slide shows the number of Respiratory indicators in the bottom quintile of the practice cluster.

Each coloured bar represents a different set of indicators e.g. dark blue is prevalence. The specific indicators are then

shown in the table on slides 20-24 for the 3 practices with the highest total number of indicators in the bottom quintile

64


Each coloured bar

represents a different set

of indicators e.g. dark

blue is prevalence. The

specific indicators are

then shown in the table

on slides 19-23 for the 3

practices with the highest

total number of indicators

in the bottom quintile

1

1

1

2

1

1

1

1

2

1

1

1

1

2

2

2

3

3

2

2

1

4

1

1

3

6

7

8

7

5

4

4

8

6

11

6

5

5

13

14

5

2

21

11

7

11

10

18

8

6

18

9

3

1

3

1

1

2

2

5

4

3

2

4

3

6

5

4

2

3

7

8

2

4

6

5

6

4

6

9

9

10

5

4

2

1

3

6

6

6

1

3

5

6

4

5

1

3

2

5

5

1

5

3

4

5

1

1

2

5

5

6

5

5

3

2

3

5

4

6

3

5

1

3

8

6

6

9

8

7

6

8

4

7

4

9

12

3

11

12

8

9

2

8

10

7

11

0 5 10 15 20 25 30 35 40 45

Milnrow Village Practice (P86001)

Heady Hill Surgery (P86602)

The Junction Surgery (P86010)

Yorkshire St Surgery (P86005)

Drake Street Surgery (P86622)

The Dawes Family Practice…

Healey Surgery (P86013)

Peterloo Medical Centre (P86004)

Dr IK Babar (P86014)

Pennine Surgery (P86021)

Argyle Street Medical Ctr (P86016)

Castleton Health Centre (P86009)

Ashworth Street Surgery (P86006)

Longford Street Medical Centre…

Tweedale Street Surgery (P86614)

Durnford Medical Centre (P86019)

Woodside Medical Centre…

The Village Medical Ctr. (P86608)

Family Practice (P86606)

Mark Street Surgery (P86008)

Vicars Drive Surgery (P86002)

Stonefield Street Surgery (P86022)

Rochdale Road Medical Centre…

Wellfield Health Centre (P86007)

Inspire Medical Centre (P86017)

Hopwood Medical Centre (P86023)

Edenfield Road Surgery (P86003)

Trinity Medical Centre (P86624)

Windermere Surgery (P86620)

Littleborough Group Practice…

York House Surgery (P86605)

Dr HB Syed (P86609)

Baillie Street Health Ctr (P86619)

Prevalence (4 indicators)

Management in Primary Care (33 indicators)

Respiratory Spend and Admissions (16 indicators)

COPD Spend and Admissions (8 indicators)

Asthma Spend and Admissions (7 indicators)

Other Respiratory Spend and Admissions (19 indicators)

65

The table shows the 3 GP practices with the highest total number of respiratory indicators in the

bottom quintile of the practice cluster group, as depicted on the previous slide. ‘Opportunities’ for the

practice to reach the cluster group average are shown against all of the indicators where applicable,

and those highlighted in red are in the bottom quintile. 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?’


'Opportunities are shown as ‘Fewer’ when, to reach the benchmark average, would represent ‘X fewer

smokers/admissions/deaths'. Opportunities are shown as ‘Extra/More Managed’ when, to reach the benchmark average would

represent ‘X additional patients managed’

Pathway step Indicator


*40 indicators in bottom quintile

of practice cluster

Dr HB Syed (P86609)


of practice cluster



of practice cluster

Percentage of patients registered with a GP aged 15+ recorded as current smoker no opportunities no opportunities 352 fewer smokers

QOF COPD prevalence no opportunities 4 fewer COPD cases 7 fewer COPD cases

Ratio of reported to expected COPD prevalence 6 extra patients to be diagnosed 3 extra patients to be diagnosed no opportunities

QOF Asthma prevalence 47 fewer asthma cases no opportunities no opportunities

Prevalence

66


'Opportunities are shown as ‘Fewer’ when, to reach the benchmark average, would represent ‘X fewer cases/admissions/deaths'.

Opportunities are shown as ‘Extra/More Managed’ when, to reach the benchmark average would represent ‘X additional patients

managed’




of practice cluster

Dr HB Syed (P86609)


of practice cluster



of practice cluster

Respiratory Secondary care cost prescribed per 1000 population £12,376 reduction £515 reduction no opportunities

Respiratory Secondary care items prescribed per 1000 population 5546 fewer items prescribed 486 fewer items prescribed 703 fewer items prescribed

Inhaled Corticosteroids per STAR PU Cost no opportunities no opportunities £2,665 reduction

Inhaled Corticosteroids per STAR PU Items Prescribed no opportunities no opportunities 2665 fewer items prescribed

Inhaled Corticosteroids Average Cost per ADQ £6,025 reduction £792 reduction no opportunities

COPD Secondary care cost prescribed per 1000 population £2,349 reduction no opportunities £270 reduction

COPD Secondary care items prescribed per 1000 population no opportunities no opportunities 238 fewer items prescribed

Asthma Secondary care cost prescribed per 1000 population no opportunities £842 reduction no opportunities

Asthma Secondary care items prescribed per 1000 population 277 fewer items prescribed 9 fewer items prescribed 238 fewer items prescribed

Other Respiratory Secondary care cost prescribed per 1000 population £10,814 reduction £1,390 reduction no opportunities

Other Respiratory Secondary care items prescribed per 1000 population 5360 fewer items prescribed 486 fewer items prescribed 227 fewer items prescribed

% with COPD who have had influenza immunisation in last year (COPD8) no opportunities 2 additional patients managed no opportunities

% with COPD who have had influenza immunisation in last year plus exceptions (COPD8) 1 additional patient managed no opportunities no opportunities

% with COPD with a record of FeV1 in the last 15 months (COPD10) no opportunities 3 additional patients managed 9 additional patients managed

% with COPD with a record of FeV1 in the last 15 months plus exceptions (COPD10) no opportunities 1 additional patient managed 7 additional patients managed

% with COPD who have had a review including assessment of breathlessness in last 15 months (COPD13) no opportunities 4 additional patients managed 5 additional patients managed

% with COPD who have had a review including assessment of breathlessness in last 15 months plus exceptions (COPD13) no opportunities 2 additional patients managed 6 additional patients managed

% with asthma aged 14-19 with record of smoking status in last 15 months (Asthma10) 2 additional patients recorded no opportunities no opportunities

% with asthma aged 14-19 with record of smoking status in last 15 months plus exceptions (Asthma10) 2 additional patients recorded no opportunities no opportunities

% with asthma with review in last 15 months (Asthma9) no opportunities 2 additional patients managed 9 additional patients managed

% with asthma with review in last 15 months plus exceptions (Asthma9) no opportunities no opportunities 8 additional patients managed

% aged 8+ with measures of variability or reversibility (Asthma8) no opportunities 12 additional patients managed 3 additional patients managed

% aged 8+ with measures of variability or reversibility plus exceptions (Asthma8) 17 additional patients managed 11 additional patients managed 3 additional patients managed

Patients with a LTC with record of smoking status (Smoke05) 13 additional patients recorded 19 additional patients recorded no opportunities

Patients with a LTC with record of smoking status plus exceptions (Smoke05) 16 additional patients recorded 14 additional patients recorded no opportunities

Patients with a LTC who smoke with a record of offer of support and treatment (Smoke06) no opportunities 7 additional patients managed 13 additional patients managed

Patients with a LTC who smoke with a record of offer of support and treatment plus exceptions (Smoke06) no opportunities 7 additional patients managed 15 additional patients managed

Patients aged 15+ with a record of smoking status in last 27 months (Smoke07) 50 additional patients recorded 564 additional patients recorded no opportunities

Patients aged 15+ with a record of smoking status in last 27 months plus exceptions (Smoke07) 27 additional patients recorded 583 additional patients recorded no opportunities

Patients aged 15+ recorded as a current smoker with offer of support and treatment in last 27 months (Smoke08) no opportunities 62 additional patients managed no opportunities

Patients aged 15+ recorded as a current smoker with offer of support and treatment in last 27 months plus exceptions (Smoke08) no opportunities 62 additional patients managed no opportunities

Seasonal flu vaccine uptake, age 6 months to 64 years 201 more vaccinated 21 more vaccinated no opportunities

Seasonal flu vaccine uptake, age 65+ years no opportunities 13 more vaccinated no opportunities

Management in

Primary Care

67





of practice cluster

Dr HB Syed (P86609)


of practice cluster



of practice cluster

Respiratory Secondary care spend per 1000 population £108,762 reduction £25,607 reduction £60,025 reduction

Respiratory Inpatient spend per 1000 population £31,906 reduction £14,142 reduction £293 reduction

Respiratory Daycase spend per 1000 population £3,283 reduction £4,359 reduction £20,395 reduction

Respiratory Emergency spend per 1000 population £76,510 reduction £8,369 reduction £41,811 reduction

Respiratory Secondary care admissions per 1000 population 96 fewer admissions 17 fewer admissions 61 fewer admissions

Respiratory Inpatient admissions per 1000 population 15 fewer admissions 3 fewer admissions 2 fewer admissions

Respiratory Daycase admissions per 1000 population 5 fewer admissions 1 fewer admission 16 fewer admissions

Respiratory Emergency admissions per 1000 population 76 fewer admissions 13 fewer admissions 43 fewer admissions

Respiratory Secondary care spend per admission no opportunities no opportunities no opportunities

Respiratory Inpatient spend per admission £452 reduction £1,434.1 reduction no opportunities

Respiratory Emergency spend per admission no opportunities no opportunities no opportunities

Respiratory Secondary care admissions Mean LOS no opportunities no opportunities no opportunities

Respiratory Inpatient admissions Mean LOS 13 fewer bed days 8 fewer bed days no opportunities

Respiratory Emergency admissions Mean LOS no opportunities no opportunities no opportunities

Under 75 years Elective Respiratory Admissions DSR per 100,000 30 fewer admissions 8 fewer admissions 36 fewer admissions

Under 75 years Emergency Respiratory Admissions DSR per 100,000 142 fewer admissions 17 fewer admissions 74 fewer admissions

Respiratory Spend

and Admissions

68



Clay Cross Medical Centre

(C81056)


of practice cluster

Blue Dykes Surgery (C81008)


of practice cluster

St Lawrence Road Surgery

(C81647)


of practice cluster

COPD Secondary care spend per 1000 population £12,113 reduction no opportunities £4,920 reduction

COPD Emergency spend per 1000 population £3,535 reduction no opportunities £5,575 reduction

COPD Secondary care admissions per 1000 population 8 fewer admissions no opportunities 10 fewer admissions

COPD Emergency admissions per 1000 population 3 fewer admissions no opportunities 10 fewer admissions

COPD Secondary care admissions per COPD register 13 fewer admissions 2 fewer admissions 19 fewer admissions

COPD Secondary care admissions Mean LOS no opportunities no opportunities no opportunities

COPD Emergency admissions Mean LOS no opportunities no opportunities no opportunities

Under 75 years Emergency COPD Admissions DSR per 100,000 19 fewer admissions no opportunities 22 fewer admissions

Asthma Secondary care spend per 1000 population £18,916 reduction £2,989 reduction £38,839 reduction

Asthma Emergency spend per 1000 population £19,626 reduction £3,295 reduction £14,230 reduction

Asthma Secondary care admissions per 1000 population 16 fewer admissions 4 fewer admissions 34 fewer admissions

Asthma Emergency admissions per 1000 population 19 fewer admissions 4 fewer admissions 10 fewer admissions

Asthma Emergency admissions per Asthma register 32 fewer admissions 10 fewer admissions 38 fewer admissions

Asthma Secondary care admissions Mean LOS no opportunities no opportunities 13 fewer bed days

Asthma Emergency admissions Mean LOS no opportunities no opportunities 19 fewer bed days

COPD Spend and

Admissions

Asthma Spend and

Admissions

69



Clay Cross Medical Centre

(C81056)


of practice cluster

Blue Dykes Surgery (C81008)


of practice cluster

St Lawrence Road Surgery

(C81647)


of practice cluster

Other Respiratory Secondary care spend per 1000 population £76,682 reduction £22,997 reduction £16,666 reduction

Other Respiratory Inpatient spend per 1000 population £24,805 reduction £14,194 reduction no opportunities

Other Respiratory Daycase spend per 1000 population £2,191 reduction £4,615 reduction no opportunities

Other Respiratory Emergency spend per 1000 population £52,170 reduction £5,273 reduction £22,314 reduction

Other Respiratory Secondary care admissions per 1000 population 69 fewer admissions 13 fewer admissions 20 fewer admissions

Other Respiratory Inpatient admissions per 1000 population 14 fewer admissions 3 fewer admissions 1 fewer admission

Other Respiratory Daycase admissions per 1000 population 2 fewer admissions 2 fewer admissions no opportunities

Other Respiratory Emergency admissions per 1000 population 36 fewer admissions 2 fewer admissions 10 fewer admissions

Other Respiratory Secondary care admissions Mean LOS no opportunities no opportunities no opportunities

Other Respiratory Inpatient admissions Mean LOS 10 fewer bed days 9 fewer bed days no opportunities

Other Respiratory Emergency admissions Mean LOS no opportunities no opportunities no opportunities

Pneumonia All Ages Emergency Admissions DSR per 100,000 no opportunities no opportunities 13 fewer admissions

Pneumonia <75 Emergency Admissions DSR per 100,000 2 fewer admissions no opportunities 11 fewer admissions

Pneumonia 75+ Emergency Admissions DSR per 100,000 no opportunities no opportunities 2 fewer admissions

Flu All Ages Emergency Admissions DSR per 100,000 no opportunities no opportunities no opportunities

Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000 36 fewer admissions 4 fewer admissions 15 fewer admissions

Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000 37 fewer admissions 4 fewer admissions 15 fewer admissions

Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000 54 fewer admissions 3 fewer admissions 13 fewer admissions

Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000 38 fewer admissions 5 fewer admissions 12 fewer admissions

Other Respiratory

Spend and

Admissions

70

CCGs should consider what local intelligence is available to further triangulate with the intelligence in

this pack. This may include:

• Practice variation analyses

• Reviewing referral protocols and guidelines

• Analysis from Acute Trust quality dashboard or other provider data

• Contract monitoring data

• 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

There are also many resources available on www.rightcare.nhs.uk to take forwards the improvement

agenda.

5. Bringing it all together – Where to focus, what could work, who should

we speak to

71

http://www.rightcare.nhs.uk/

5. National Guidance

• British Lung Foundation (2007) Invisible lives: chronic obstructive pulmonary

disease (COPD) finding the missing millions.

• Department of Health (2010) Consultation on a strategy for services for

chronic obstructive pulmonary disease (COPD) in England – impact

assessment. London: Department of Health

• Healthcare Commission (2006) Clearing the air: a national study of chronic

obstructive pulmonary disease. London: Healthcare Commission.

• NICE (2010) Chronic obstructive pulmonary disease: management of

chronic obstructive pulmonary disease in adults in primary and secondary

care (partial update). NICE clinical guideline 101. London: National Institute

for Health and Clinical Excellence. Available from

www.nice.org.uk/guidance/CG101

72

5. National Guidance

• The Kings fund 2010 : Avoiding Hospital Admissions

• Chronic obstructive pulmonary disease: management of chronic obstructive

pulmonary disease in adults in primary and secondary care. NICE clinical

guideline 12 (2004). [Replaced by NICE clinical guideline 101]

• British Guideline on the Management of Asthma: SIGN101, ISBN 978 1

90581 28 5, May 2008, Revised May 2011, Section 4.3.4 revised Sept 2011,

Section 1 revised Jan 2012

73

Annexes

Annex 1 – Spine charts and opportunity tables

Annex 2 – CCG Cluster Classification

Annex 3 – Practice Cluster Classification

Annex 4 – Indicator List

Glossary

74

Annex 1: Spine Charts

Prevalence / Diagnosis

Benchmark average Benchmark Top Quintile

6096 fewer smokers 10437 fewer smokers

1439 fewer COPD cases 2740 fewer COPD cases

No Opportunity 249 extra patients to be diagnosed

No Opportunity 14 additional patients managed

No Opportunity No Opportunity

2518 fewer asthma cases 4230 fewer asthma cases

Opportunities

0 20 40 60 80 100

Percentage of patients registered with a GP aged 15+ recorded as current smoker

QOF COPD prevalence

Ratio of reported to expected COPD prevalence

% COPD diagnosis confirmed by post bronchodilator spirometry

% COPD diagnosis confirmed by post bronchodilator spirometry plus exceptions

QOF Asthma prevalence

Worse Outcome Better Outcome

75


Primary Care


£1536312 reduction £2599692 reduction

89915 fewer items prescribed 145501 fewer items prescribed





36 additional patients managed 86 additional patients managed









No Opportunity 7 additional patients recorded

3 additional patients recorded 26 additional patients recorded





101 fewer exceptions 586 fewer exceptions



Opportunities

0 20 40 60 80 100

Respiratory Cost prescribed per 1000 population

Respiratory Items prescribed per 1000 population

Inhaled Corticosteroids ADQ per STAR PU Cost

Inhaled Corticosteroids ADQ per STAR PU Items Prescribed

COPD Cost prescribed per 1000 population

COPD Items prescribed per 1000 population

% with COPD who have had influenza immunisation

% with COPD who have had influenza immunisation plus exceptions

% with COPD with a record of FeV1

% with COPD with a record of FeV1 plus exceptions

% with COPD who have had a review

% with COPD who have had a review plus exceptions

Total COPD Exceptions

Asthma Cost prescribed per 1000 population

Asthma Items prescribed per 1000 population

% with asthma aged 14-19 with record of smoking status

% with asthma aged 14-19 with record of smoking status plus exceptions

% with asthma with review in last 15 months

% with asthma with review in last 15 months plus exceptions

% aged 8+ with measures of variability or reversibility

% aged 8+ with measures of variability or reversibility plus exceptions

Total Asthma Exceptions

Other Respiratory Cost prescribed per 1000 population

Other Respiratory Items prescribed per 1000 population

Worse outcome Better outcome

76


Primary Care










No Opportunity 100 fewer exceptions



Opportunities

Better outcome

0 20 40 60 80 100

Patients with a LTC with record of smoking status

Patients with a LTC with record of smoking status plus exceptions

Patients with a LTC who smoke with a record of offer of support and treatment

Patients with a LTC who smoke with a record of offer of support and treatment plus exceptions

Patients aged 15+ with a record of smoking status

Patients aged 15+ with a record of smoking status plus exceptions

Patients aged 15+ recorded as a current smoker with offer of support and treatment

Patients aged 15+ recorded as a current smoker with offer of support and treatment plus…

Total Smoking Exceptions

Seasonal flu vaccine uptake, age 6 months to 64 years

Seasonal flu vaccine uptake, age65+ years

Worse outcome

77


Secondary Care




No Opportunity £15193 reduction


1410 fewer admissions 1958 fewer admissions


No Opportunity 63 fewer admissions



No Opportunity £111 reduction




130 fewer bed days 258 fewer bed days




Opportunities

0 20 40 60 80 100

Respiratory Secondary care spend per 1000 population

Respiratory Inpatient spend per 1000 population

Respiratory Daycase spend per 1000 population

Respiratory Emergency spend per 1000 population

Respiratory Secondary care admissions per 1000 population

Respiratory Inpatient admissions per 1000 population

Respiratory Daycase admissions per 1000 population

Respiratory Emergency admissions per 1000 population

Respiratory Secondary care spend per admission

Respiratory Inpatient spend per admission

Respiratory Daycase spend per admission

Respiratory Emergency spend per admission

Respiratory Secondary admissions Mean LOS

Respiratory Inpatient admissions Mean LOS

Respiratory Emergency admissions Mean LOS

Under 75 years Elective Respiratory Admissions DSR per 100,000

Under 75 years Emergency Respiratory Admissions DSR per 100,000

Worse outcome / Higher spend

Better outcome / Low er spend

78


Secondary Care


















Opportunities

Opportunities

0 20 40 60 80 100

COPD Secondary care spend per 1000 population

COPD Emergency spend per 1000 population

COPD Secondary care admissions per 1000 population

COPD Emergency admissions per 1000 population

COPD Secondary care admissions per COPD register

COPD Secondary care admissions Mean LOS

COPD Emergency admissions Mean LOS

Under 75 years Emergency COPD Admissions DSR per 100,000



0 20 40 60 80 100

Asthma Secondary care spend per 1000 population

Asthma Emergency spend per 1000 population

Asthma Secondary care admissions per 1000 population

Asthma Emergency admissions per 1000 population

Asthma Secondary care admissions per Asthma register

Asthma Secondary care admissions Mean LOS

Asthma Emergency admissions Mean LOS



79


Secondary Care









118 fewer bed days 244 fewer bed days











Mortality


9 fewer deaths 30 fewer deaths



Opportunities

Opportunities

0 20 40 60 80 100

Under 75 Respiratory Mortality DSR per 100,000

Mortality from asthma DSR per 100,000

Under 75 Mortality from bronchitis and emphysema and COPD DSR per 100,000

Worse outcome Better outcome

0 20 40 60 80 100

Other Respiratory Secondary care spend per 1000 population

Other Respiratory Inpatient spend per 1000 population

Other Respiratory Emergency spend per 1000 population

Other Respiratory Secondary care admissions per 1000 population

Other Respiratory Inpatient admissions per 1000 population

Other Respiratory Emergency admissions per 1000 population

Other Respiratory Secondary care admissions Mean LOS

Other Respiratory Inpatient admissions Mean LOS

Other Respiratory Emergency admissions Mean LOS

Emergency admissions for children with lower respiratory disease

Pneumonia All Ages Emergency Admissions DSR per 100,000

Pneumonia <75 Emergency Admissions DSR per 100,000

Pneumonia 75+ Emergency Admissions DSR per 100,000

Flu All Ages Emergency Admissions DSR per 100,000

Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000

Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000

Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000

Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000



80


Cluster Classification Group

0-19

years

20-39

years

40-59

years

60-79

years

80+

years

Population

from Black

ethnic

groups

Population

from Asian

ethnic

groups

Population

density

(persons

per hectare)

Average

IMD

2010

score

Purple An older population living in rural areas

and low deprivation levels 22.3% 22.0% 27.8% 21.9% 6.0% 0.5% 1.9% 1.9 16.85

Blue

A very young population with a high

proprtion of the population from Black and

Asian ethnic groups and high levels of

deprivation.

26.4% 41.1% 21.3% 9.0% 2.1% 16.2% 31.6% 80.4 40.78

Green

A younger population with a high

proportion of the population from Black

and Asian ethnic groups and moderate

levels of deprivation.

21.6% 42.0% 23.5% 10.4% 2.5% 16.7% 10.3% 100.1 28.81

Yellow

A younger population with a higher than

average proportion of the population from

Black and Asian ethnic groups and

moderate levels of deprivation.

26.0% 31.6% 24.5% 14.1% 3.7% 6.7% 17.7% 26.2 29.00

Orange

A population with an average age

structure, average deprivation levels and

a low population density. 24.2% 25.3% 27.9% 18.2% 4.5% 1.5% 4.6% 5.1 20.38

The CCG Cluster groups are taken from YHPHO methodology, which groups together CCGs with similar populations. It is

based on statistical cluster analysis (K-means analysis) including variables of age structure of the population, the population

from Black and Asian ethnic groups, population density and deprivation.

81


Heywood, Middleton & Rochdale CCG is in the Yellow Cluster Group. The constituent CCG’s are listed

below.

Code CCG Name Code CCG Name00G NHS Newcastle North and East CCG 06P NHS Luton CCG00H NHS Newcastle West CCG 07L NHS Barking and Dagenham CCG00Q NHS Blackburn with Darwen CCG 07M NHS Barnet CCG00Y NHS Oldham CCG 07V NHS Croydon CCG01D NHS Heywood, Middleton and Rochdale CCG 07W NHS Ealing CCG01G NHS Salford CCG 07X NHS Enfield CCG01M NHS North Manchester CCG 07Y NHS Hounslow CCG01N NHS South Manchester CCG 08A NHS Greenwich CCG02R NHS Bradford Districts CCG 08E NHS Harrow CCG03C NHS Leeds West CCG 08G NHS Hillingdon CCG03F NHS Hull CCG 08J NHS Kingston CCG03G NHS Leeds South and East CCG 08N NHS Redbridge CCG03J NHS North Kirklees CCG 08R NHS Merton CCG03N NHS Sheffield CCG 09H NHS Crawley CCG04C NHS Leicester City CCG 10R NHS Portsmouth CCG04F NHS Milton Keynes CCG 10T NHS Slough CCG04K NHS Nottingham City CCG 10W NHS South Reading CCG04X NHS Birmingham South and Central CCG 10X NHS Southampton CCG05A NHS Coventry and Rugby CCG 11H NHS Bristol CCG05L NHS Sandwell and West Birmingham CCG 13P NHS Birmingham Crosscity CCG05Y NHS Walsall CCG 99A NHS Liverpool CCG06A NHS Wolverhampton CCG

82

Annex 3: Practice cluster classification

The practice cluster groups are taken from YHPHO methodology, which groups together practices with similar populations. It

is based on statistical cluster analysis (K-means analysis) including variables of age structure of the population, the

population from Black and Asian ethnic groups, rural classification and deprivation. A total of 8074 GP practices were grouped

into ten classification groups. A small number of practices (354 covering 1.1% of the population) did not have sufficient data to

allocate them to a classification group

83

Annex 3: Practice cluster classification

The practice cluster groups are taken from YHPHO methodology, which groups together practices with similar populations. It

is based on statistical cluster analysis (K-means analysis) including variables of age structure of the population, the

population from Black and Asian ethnic groups, rural classification and deprivation. A total of 8074 GP practices were grouped

into ten classification groups. A small number of practices (354 covering 1.1% of the population) did not have sufficient data to

allocate them to a classification group

Practices in Heywood, Middleton & Rochdale CCG and the practice cluster benchmark group

Practice

Cluster

Name

Practice

Code Practice Name

P86003 Edenfield Road Surgery

P86018 Littleborough Group Practice

P86001 Milnrow Village Practice

P86004 Peterloo Medical Centre

P86005 Yorkshire St Surgery

P86007 Wellfield Health Centre

P86008 Mark Street Surgery

P86009 Castleton Health Centre

P86010 The Junction Surgery

P86011 Longford Street Medical Centre

P86015 Rochdale Road Medical Centre

P86019 Durnford Medical Centre

P86021 Pennine Surgery

P86605 York House Surgery

P86622 Drake Street Surgery

Kite

Oval

Practice

Cluster

Name

Practice

Code Practice Name

P86022 Stonefield Street Surgery

P86023 Hopwood Medical Centre

P86608 The Village Medical Ctr.

P86624 Trinity Medical Centre

P86014 Dr IK Babar

P86017 Inspire Medical Centre

P86609 Dr HB Syed

P86614 Tweedale Street Surgery

P86619 Baillie Street Health Ctr

P86002 Vicars Drive Surgery

P86006 Ashworth Street Surgery

P86012 Woodside Medical Centre

P86013 Healey Surgery

P86016 Argyle Street Medical Ctr

P86026 The Dawes Family Practice

P86602 Heady Hill Surgery

P86606 Family Practice

P86620 Windermere Surgery

Pentagon

Square

Triangle

84

Annex 4: Full indicator list

Pathway Step Indicator/Data Source Year

Prevalence Percentage of patients registered with a GP aged 15+ recorded as current smokerQOF 2012/13

Prevalence QOF COPD prevalence QOF (NHS IC) 2012/13

Prevalence Ratio of reported to expected COPD prevalence QOF (NHS IC) 2012/13

Prevalence % COPD diagnosis confirmed by post bronchodilator spirometry (COPD15) QOF (NHS IC) 2012/13

Prevalence % COPD diagnosis confirmed by post bronchodilator spirometry plus exceptions (COPD15)QOF (NHS IC) 2012/13

Prevalence QOF Asthma prevalence QOF (NHS IC) 2012/13

Primary Care Total Respiratory Cost prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care Total Respiratory Items prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care Inhaled Corticosteroids ADQ per STAR PU Cost NHS Comparators (NHS IC) 2012/13

Primary Care Inhaled Corticosteroids ADQ per STAR PU Items Prescribed NHS Comparators (NHS IC) 2012/13

Primary Care Total COPD Cost prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care Total COPD Items prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care % with COPD who have had influenza immunisation in last year (COPD8) QOF 2012/13

Primary Care % with COPD who have had influenza immunisation in last year plus exceptions (COPD8)QOF 2012/13

Primary Care % with COPD with a record of FeV1 in the last 15 months (COPD10) QOF 2012/13

Primary Care % with COPD with a record of FeV1 in the last 15 months plus exceptions (COPD10)QOF 2012/13

Primary Care % with COPD who have had a review including assessment of breathlessness in last 15 months (COPD13)QOF 2012/13

Primary Care % with COPD who have had a review including assessment of breathlessness in last 15 months plus exceptions (COPD13)QOF 2012/13

Primary Care COPD Exceptions QOF 2012/13

Primary Care Total Asthma Cost prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care Total Asthma Items prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care % with asthma aged 14-19 with record of smoking status in last 15 months (Asthma10)QOF 2012/13

Primary Care % with asthma aged 14-19 with record of smoking status in last 15 months plus exceptions (Asthma10)QOF 2012/13

Primary Care % with asthma with review in last 15 months (Asthma9) QOF 2012/13

Primary Care % with asthma with review in last 15 months plus exceptions (Asthma9) QOF 2012/13

Primary Care % aged 8+ with measures of variability or reversibility (Asthma8) QOF 2012/13

Primary Care % aged 8+ with measures of variability or reversibility plus exceptions (Asthma8) QOF 2012/13

Primary Care Total Asthma Exceptions QOF 2012/1385

Annex 4: Full indicator list (cont.)


Primary Care Total Other Respiratory Cost prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care Total Other Respiratory Items prescribed per 1000 population NHS Comparators (NHS IC) 2012/13

Primary Care Patients with a LTC with record of smoking status (Smoke05) QOF 2012/13

Primary Care Patients with a LTC with record of smoking status plus exceptions (Smoke05) QOF 2012/13

Primary Care Patients with a LTC who smoke with a record of offer of support and treatment (Smoke06)QOF 2012/13

Primary Care Patients with a LTC who smoke with a record of offer of support and treatment plus exceptions (Smoke06)QOF 2012/13

Primary Care Patients aged 15+ with a record of smoking status in last 27 months (Smoke07) QOF 2012/13

Primary Care Patients aged 15+ with a record of smoking status in last 27 months plus exceptions (Smoke07)QOF 2012/13

Primary Care Patients aged 15+ recorded as a current smoker with offer of support and treatment in last 27 months (Smoke08)QOF 2012/13

Primary Care Patients aged 15+ recorded as a current smoker with offer of support and treatment in last 27 months plus exceptions (Smoke08)QOF 2012/13

Primary Care Total Smoking Exceptions QOF 2012/13

Primary Care Seasonal flu vaccine uptake, age 6 months to 64 years Practice Profiles 2010/11

Primary Care Seasonal flu vaccine uptake, age 65+ years Practice Profiles 2010/11

Secondary Care Total Respiratory spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Inpatient spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Daycase spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Emergency spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Inpatient admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Daycase admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Emergency admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory spend per admission NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Inpatient spend per admission NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Daycase spend per admission NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Emergency spend per admission NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Inpatient admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Total Respiratory Emergency admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Under 75 years Elective Respiratory Admissions DSR per 100,000 HES 2012/13

Secondary Care Under 75 years Emergency Respiratory Admissions DSR per 100,000 HES 2012/1386

Annex 4: Full indicator list (cont.)


Secondary Care Total COPD spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total COPD Emergency spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total COPD admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total COPD Emergency admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total COPD admissions per COPD register NHS Comparators (NHS IC) 2012/13

Secondary Care Total COPD admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Total COPD Emergency admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Under 75 years Emergency COPD Admissions DSR per 100,000 HES 2012/13

Secondary Care Total Asthma spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Asthma Emergency spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Asthma admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Asthma Emergency admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Asthma Emergency admissions per Asthma register NHS Comparators (NHS IC) 2012/13

Secondary Care Total Asthma admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Total Asthma Emergency admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory Inpatient spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory Emergency spend per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory Inpatient admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory Emergency admissions per 1000 population NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory Inpatient admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Total Other Respiratory Emergency admissions Mean LOS NHS Comparators (NHS IC) 2012/13

Secondary Care Emergency admissions for children with lower respiratory disease NHS Comparators (NHS IC) 2012/13

Secondary Care Pneumonia All Ages Emergency Admissions DSR per 100,000 HES 2012/13

Secondary Care Pneumonia <75 Emergency Admissions DSR per 100,000 HES 2012/13

Secondary Care Pneumonia 75+ Emergency Admissions DSR per 100,000 HES 2012/13

Secondary Care Flu All Ages Emergency Admissions DSR per 100,000 HES 2012/13

Secondary Care Upper Respiratory Infection All Ages Emergency Admissions DSR per 100,000 HES 2012/13

Secondary Care Upper Respiratory Infection <75 Emergency Admissions DSR per 100,000 HES 2012/13

Secondary Care Lower Respiratory Infection All Ages Emergency Admissions DSR per 100,000 HES 2012/13

Secondary Care Lower Respiratory Infection <75 Emergency Admissions DSR per 100,000 HES 2012/13

Mortality Under 75 Respiratory Mortality DSR per 100,000 NHS Comparators (NHS IC) 2012/13

Mortality Mortality from asthma DSR per 100,000 CFV Packs 2009-11

Mortality Under 75 Mortality from bronchitis and emphysema and COPD DSR per 100,000 CFV Packs 2009-11

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Glossary

Patients registered with a GP aged 15+ recorded as current smoker: Denominator taken from QOF Smoke07 denominator (Number of patients aged 15+), Numerator taken from QOF Smoke08 denominator (Number of patients aged 15+ with smoking status recorded)

Expected CCOPD Prevalence: Aggregated from the East of England PHO practice level modelled disease prevalence estimates 2011

QOF Exceptions : Total exceptions across al management indicators

Spend and Admissions: The rate in terms of activity and Payment by Results (PbR) tariff based cost per 1000 practice population. Denominator data: Population based on GP list data. Numerator data: Count of completed spells and sum of PbR tariff. Excludes activity not covered by mandatory PbR Tariffs.

DSR per 100,000: Directly age standardised rate calculated by taking the age-specific crude rates and applying them to the European Standard Population. Age-standardised rates take into account the variation in the age structures of populations

All Respiratory diseases: primary diagnosis of J00-J99

Pneumonia: primary diagnosis J12-J18

Flu: primary diagnosis J09-J11

Acute Upper Respiratory Infection: primary diagnosis J00-J06

Acute Lower Respiratory Infection : primary diagnosis J20-J22

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