1. Improving general practice in east London John Robson General practitioner, Tower Hamlets Clinical Effectiveness Group, east London Reader, Barts and the London, Queen Mary University of London

2. The story Steady improvement applying known tools and high quality infrastructure until.....

3. Clinical PCT CEG Academi c Guidelines Content Data entry Dashboards Recall Reports

4. % statin for CHD East London Timeline: CHD and statins HEP Statin CEG NSF Simva Alwen NICE 1 PCT trials 3 PCT CVD generic QoF lipid EMIS LES CVD Acheson Wanless Spearhead Network Care Package

5. Step change – good to excellent Finance Priority Inform– Dashboards and recall Organisation

6. East London diabetes belt Feasibility study of geospatial mapping of chronic disease risk to inform public health commissioning.Feasibility study of geospatial mapping of chronic disease risk to inform public health commissioning. Noble D, Smith D, Mathur R, Robson J, Greenhalgh T. BMJ Open. 2012 Feb 15;2(1):e000711. Print 2012.

7. Whats new? 2011-1898

8. CHD Mortality 1980-2006 National success

9. Tower Hamlets Hackney Newham CHD Mortality<75yrs x Deprivation (IMD): English LA 2006-8

10. Where we are today Male life expectancy 2002-9

11. Population 800 000 in 3 PCTs 500 GPs in 150 practices All EMIS Web except 4 practices Equity: 90% ethnicity recording & social deprivation

12. Where did we start ?

13. Priority, Guidance and Audit Education In Practice facilitation

14. Statins for CHD 1999 – 2010

15. Tower Hamlets 2003-10 Low cost statins as % all statins Local

17. Declining CHD Increasing diabetes THamlets

18. What to do? Resource PCT leadership and money Engage Integrate clinical guidance, in-practice facilitation, data collection and real time IT visualisation Priority LES and Care Packages Organisation Practice networks : Health care assistants Equity in-built

19. Investment moves Tower Hamlets from near bottom to the top for primary care spend Note:TH would still have spent less as a % of total spend on primary care than either N Lancs or Peterborough (both at 15.6%) Source:Laing & Buisson NHS Financial Report 2006/07, Department of Health exposition book 2006/07 % PCT spend on primary care 2006/7 Growth post Wanless Tower Hamlets TH before investment TH after investment

20. Resources Circulatory disease: total spend per head population TH lowest spend/head of all PCTs in 2006 (YHPHO) 20062009 Tower Hamlets 94161 Middlesborough 167120

21. What did we do? Expanded our LES to Care Packages Improved our IT Invested in training new staff – Health care assistants, specialist diabetes nurses, Set up networks with manager+ 1 staff in each local neighbourhood

22. Neighbourhood Networks Step change 36 Tower Hamlets practices 8 geographical networks Network staff£1.2m Care packages£3.5m LES £3m Total £8m

23. 23 6 5 * 1 2 3 4 5 6 8 9 10 7 11 12 15 13 16 14 17 18 19 24 21 22 20 23 25 26 27 28 29 30 31 32 33 34 35 36 Pop: 28,956 Pop: 23,868 Pop: 38,529 Pop: 33,948 Pop: 25,549 36 Practices in 8 neighbourhood networks Neighbourhood Networks

24. Care Packages Diabetes COPD Cardiovascular Disease Childhood Immunisations Target 95% 2009 2008

25. 25 NHS Health Checks High Risk >20% Medium/ Lower Risk Hypertension On-target Off-target CVD: Secondary Prevention On-target Off-target Newly diagnosed CVD Care Packages

26. (My) Network success Direct network- practice engagement Collective & financial responsibility - NIS Timely & accurate IT recall lists Recall - dedicated staff Real time Performance: see how Im driving dashboards Peer to peer facilitation

27. Visual data High risk – statins Check BP Prompts Dashboards Maps

28. NHS Check: QRisk CVD prediction

29. Diabetes HbA1c by practice network Spitalfields Thameside

30. Network monthly rag rating chart CVD Sec Prevention TargetPaym (cumulat) PrevProgCurrent ABASCSLimehGW % %Count% % % % % of new MI patients that have attended a post-MI review by Primary Care within 3 weeks of discharge 67.0% 574/7505/10 603/5 70-74.9%1% 75-75.9%3%79.0% 80%5% 1003/3 1005/5 Percentage of post MI patients who have attended cardiac rehab within 12months of discharge 57.0% 50.0% 433/7404/10 402/5 60-65%2% 603/5 >65-70%4% >70-75%6% >75-80%8% 80%10% 1003/3 Percentage of "on target" chd/strk/tia patients (BP equal or less than 140/90 - cholesterol equal or less than 4mmols) 3029/9885/245 2319/82 35-39.99%2%35.0%36.0% 3619/53 35 40-44.99%4% 45-49.99%6% 50-54.99%8% 5175/146 55%10% Percentage of chd/str/tia patients with a care plan in last 15/12 31.0% 2956/1951415/1103218/56 70- 79.9%1.5% 80-89.5%3% 4230/71 95%5% 6726/39

31. Did we make a difference?

32. MMR Immunisation 2006-10 Improving MMR vaccination rates: herd immunity is a realistic goal Cockman P, Dawson L, Mathur R, Hull S, BMJ2011;343doi: 10.1136/bmj.d5703

33. Directed Enhanced Service for child imms (MMR1) 123Y COVER (MMR1) 12Y Health Protection Agency COVER timescale & The Direct Enhanced Service for GPs

34. Criteria Metric Target MayJuneJulyAugSeptOct This Month Last Month RAG 11100 NIS 2: Imms & Vaccs 1 1100 2 2.1 Uptake of immunisations between children aged 0-1 12 month cohort95% 98.1%97.8%97.0%97.4% 97.9% # 97.4% 3 Practice East One Health95%98.7%98.8%96.1%97.4% 98.5% Jubilee Street Practice 95%97.7%97.8%100% St Katharine Docks Practice 95%100% Wapping Group Practice 95%97.6%97.0%94.9%94.8% 95.5% 11100 1 1100 2 2.2 Uptake of immunisations between children aged 1-2 24 month cohort95% 94.0%95.3%97.8%97.2% 91.3% # 97.2% 3 Practice East One Health95%90.6%92.0%100%95.9% 94.2% Jubilee Street Practice 95%99.0% 94.7%97.0% 89.4% St Katharine Docks Practice 95%100% 100.0%100% Wapping Group Practice 95%90.8%94.0%98.2%98.3% 88.9% Imms & Vacs dashboard (OCT 2011)

35. MMR by ethnic group

37. COPD Indicators Prevalence COPD% referred to pulmonary rehab % flu vaccinationEmergency admission COPD

38. COPD and Flu immunisations No exceptions With exceptions Based on data from QOF database http://www.gpcontract.co.uk/

39. Care package performance

40. Respiratory Outpatient Activity Tower Hamlets PCT January 2011-2012 Total list size: 273,418 patients

41. *Admission rates not adjusted to the EU standard population

42. DIABETES Care package Staff Accurate and dedicated recall/list cleaning Good dashboards Clinical engagement – MDT, network meetings

43. Diabetes: BP <140/85mmHg QOF

44. Diabetes: retinopathy screening QOF

45. Diabetes: Cholesterol <5mmol/l

46. Diabetes: BP <140/85mmHg

47. <7.5<8.0

49. Diabetes HbA1c <7.5% 2004-9 Newham and Tower Hamlets

50. Hospital Admission: Diabetes London & Tower hamlets per 10,000 crude London Tower Hamlets Soljack 2011 Emergency admissions all principal diabetes comps

51. CHD: BP<150/90mmHg QOF

52. Emergency admission coronary heart disease

53. Emergency admission for stroke

54. Clinical PCT CEG Academi c Guidelines Content Data entry Dashboards Recall Reports

55. Networks are a step change

56. NHS 2012-2088

57. Thanks to Alwen Williams and Tower Hamlets PCT Ian Basnett/Somen Banarjee public health Richard Bull City and Hackney Helen Page Newham CEG GPs, staff and Networks Health Foundation QMUL

58. Maintaining improvement Intervention

59. CHD QoF Cholesterol<5 2004 -2008 by deprivation

60. % with AF on warfarin Newham practices CHADS score statins HASBLED Facilitation Education Recall listsGuideline Warfarin LES 70% anticoag