1. 1 Commissioning for Value Insight packs Online Annexes NHS England Gateway ref: 00525

2. This file contains the annexes to the CCG Commissioning for Value Insights packs distributed to CCGs, including a West Cheshire case-study, methodology information, the full list of indicators used to compile the packs. Annexes

3. 3 Year 1 – Came from behind - Implemented system mid year Year 2 – Delivered as went along - Began at year start, achieved by end Year 3 – Planned ahead - Began before year start, over-achieved Year 4 – Ahead of the curve - 20% of QIPP delivered by start Year 5 – Increased focus on quality! Achieving financial stability in West Cheshire Its not just about money - Right Care in West Cheshire led to real quality improvements in just one annual cycle -A&E attends & admissions, Elective & Non- elective activity, OP Firsts and – -Follow-ups – all decreased - Outcomes & Quality – improved - Integration occurred across health sectors and with social care Enabled by, for example : - Medicines administration training to care homes - Personalised care plans (LTC) - Community endoscopy, optometry, ophthalmology, neurology & pain management pathways - MRI Scanner Direct Access Other case studies on the above and examples from other CCGs are available from www.rightcare.nhs.uk/resourcecentre Annex 1: Why Act – Achieving financial stability in West Cheshire 3

4. 4 Annex 2: Methodology 4 How have you selected the indicators for inclusion in this pack? The indicators in this pack have been chosen to reflect the best available representation of spend, drivers of spend and outcome/quality for the highest spending disease areas. The data in this pack relates to CCG populations not necessarily just those services the CCG is directly responsible for. CCG level spend by programme is only available for admissions and prescribing. Are the data freely available? Yes, the indicators included in this pack are all derived from publicly available sources. Most of the data comes from the Health & Social Care Information Centre and Public Health England. How do you choose the CCGs closest to ours for comparison? Your CCG has been compared to a cluster group containing 10 CCGs. These are the other 10 CCGs in England which have the most similar demographic and health characteristics to your own e.g. total population, age profile, deprivation, ethnicity, and population density. What are the benchmarks? For each indicator, the first benchmark in the charts is the average value for the 10 most similar CCGs. The second benchmark in the charts is the average value for the best 5 of the 10 most similar CCGs. Only this second benchmark is used in the tables. Only indicators which are worse and statistically significantly different at the 95% confidence level from the benchmark are shown in the charts or tables.. I.e. effectively they are worse at the 97.5% confidence level.

5. 5 Annex 2: Methodology (2) 5 Which indicators are shown in the improvement opportunities charts and tables? Only indicators which are significantly different than the benchmark are shown in the pack. I.e. if the 95% confidence intervals for your CCGs value do not include the benchmark value then your CCG is an outlier. Furthermore, only indicators were the CCGs value is worse than the benchmark are shown as an improvement opportunity. For most indicators (e.g. mortality, spend), if the CCGs lower confidence interval is higher than benchmark value then the indicator appears as an improvement opportunity in the pack. E.g. the CCG could potentially save lives or reduce spend by reducing to the benchmark. For some indicators (e.g. QOF interventions), where a lower value is a worse outcome then the indicator appears as an improvement opportunity in the pack if the CCGs upper confidence interval is lower than the benchmark value. E.g. A CCG with a low % of patients with a disease under control has the improvement opportunity to increase this. The charts show the improvement opportunity using both benchmarks, the average value for the 10 most similar CCGs and the average value for the best 5 of the 10 most similar CCGs. The tables show the improvement opportunity using only the second benchmark, the average value for the best 5 of the 10 most similar CCGs. The improvement opportunities for every indicator which is worse and significantly different to the benchmark are shown in the tables. Only the most important improvement opportunities of potential savings for lives and finance are shown in the charts. How has the improvement opportunity been calculated? The improvement opportunity highlights the scale of improvement that would be achieved if the CCG were to change its performance on that indicator to the benchmark value. It is calculated using the formula: Improvement Opportunity = (CCG Value – Benchmark Value) * Denominator The denominator is the most suitable population data for that indicator. E.g. CCG registered population, CCG weighted population, CCG patients on disease register etc. The improvement opportunity is only displayed for those indicators where the CCGs value is statistically significantly different (95% confidence intervals) and then worse than the benchmark (so effectively 97.5% confidence intervals).

6. 6 Annex 3: List of Indicators (1) Full metadata for these indicators is available online - www.rightcare.nhs.uk/commissioningforvalue Data are 2011/12 unless otherwise stated Cancer % cancer prevalence 2010/11 Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population Rate of urgent GP referrals for suspected cancer per 100,000 population 2012/13 % of women aged 50-70 screened for breast cancer in last three years 2010/11-2011/12 Emergency Bed Days for Long Term Conditions per 1000 Population Mortality from all cancers under 75 years per 100,000 population 2009-11 Mortality from all cancers all ages, per 100,000 population 2009-11 Mortality from colorectal cancer under 75 per 100,000 population 2009-11 Mortality from lung cancer under 75 per 100,000 population 2009-11 Mortality from breast cancer under 75 per 100,000 population 2009-11 % receiving first definitive treatment within two months of urgent referral from GP 2012/13 Rate of successful quitters at 4-weeks per 100,000 smokers 2009/10- 2011/12 ____________________________________________________________ Endocrine % Hypothyroidism prevalence Diabetes Mellitus (diabetes) (ages 17+) prevalence 2010-11 Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Circulation % atrial fibrillation prevalence 2010/11 % stroke or transient Ischaemic Attacks (TIA) prevalence 2010-11 % hypertension prevalence 2010/11 % heart failure due to LVD prevalence 2010/11 Heart failure reported prevalence 2010/11 % coronary heart disease prevalence 2010/11 % cardiovascular disease primary prevention prevalence 2010/11 Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population % of transient ischaemic attack (TIA) cases with a higher risk who are treated within 24 hours % of patients admitted to hospital following a stroke who spend 90% of their time on a stroke unit 2012/13 Mortality from all circulatory diseases under 75 (DSR) per 100,000 population 2009-11 Mortality from coronary heart disease under 75 (DSR) per 100,000 population 2009-11 Mortality from acute MI under 75 (DSR) per 100,000 population 2009-11 Mortality from stroke under 75 (DSR) per 100,000 population 2009-11 % of patients with CHD whose last blood pressure reading is 150/90 or less % of patients with CHD whose last measured cholesterol is 5mmol/l or less Reported prevalence of CHD on GP registers as % of estimated prevalence Reported prevalence of hypertension on GP registers as a % of estimated prevalence

7. 7 Annex 3: List of Indicators (2) Net Ingredient Cost per patient on the QOF diabetes register Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population % of diabetic patients whose last cholesterol was 5mmol or less % of patients with diabetes in whom the last IFCC-HbA1c is 64mmol/mol or less % of patients with diabetes whose last blood pressure was 150/90 or less Observed vs expected number of emergency bed days for patients with diabetes _____________________________________________________________ Gastrointestinal Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population None-elective admissions per 1000 population Emergency admissions for alcohol related liver disease per 100,000 population Mortality from gastrointestinal disease under 75 per 100,000 population Mortality from liver disease under 75 per 100,000 population _____________________________________________________________ Mental Health Mental Health - % mental health prevalence 2010/11 Mental Health - % learning disabilities (ages 18+) prevalence 2010/11 Mental Health - % dementia prevalence 2010/11 Mental Health - % depression (ages 18+) prevalence 2010/11 Mental Health - Spend on FHS prescribing per 1000 population Mental Health - Total bed-days in hospital per 1000 population >74 with a secondary diagnosis of dementia Mental Health - Rate of admissions to hospital per 1000 population >74 years with a secondary diagnosis of dementia Mental Health - Emergency hospital admissions for self-harm per 100,000 Genitourinary % Chronic kidney disease (ages 18+) prevalence Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary case admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population % of patients on CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker % of patients on CKD register whose the last blood pressure reading is 140/85 or less _____________________________________________________________ Maternity Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary case admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population % of live and still births <2500 grams 2011 Teenage conceptions (aged under 18) rates per 1,000 females aged 15-17 2009 to 2011 _____________________________________________________________ Musculoskeletal Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population Hip replacement, EQ-5D, Health Gain (Provisional 2011/12) Knee replacement, EQ-5D, Health Gain (Provisional 2011/12)

8. 8 Annex 3: List of Indicators (3) % of people with mental illness and or disability in settled accommodation Improving access to psychological therapies - % recovery rate Reported numbers of admissions on GP registers as a % of estimated prevalence Excess under 75 mortality rate in adults with serious mental illness 2010/11 Mortality from suicide and injury undetermined all ages per 100,000 population 2009-11 _____________________________________________________________ Trauma and Injuries Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population Mortality from accidental causes all ages per 100,000 population 2009-11 _____________________________________________________________ Overall % palliative care prevalence 2010/11 % Obesity (ages 16+) prevalence 2010/11 Index of Multiple Deprivation 2010/11 Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on first outpatient appointment following GP referral per 1000 population Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population First outpatient appointment following GP referral per 1000 population Potential years of life lost (PYLL) FEMALE from causes considered amenable to healthcare per 100,000 2011 Potential years of life lost (PYLL) MALE from causes considered amenable to healthcare per 100,000 2011 Hip replacement, Oxford score, Health Gain (Provisional 2011/12) Knee replacement, Oxford score, Health Gain (Provisional 2011/12) _____________________________________________________________ Neurological % epilepsy (ages 18+) prevalence 2010-11 Spend on secondary care admissions per 1000 population Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population Emergency admission rate for children with epilepsy per population aged 0– 17 years 2009/10, 2010/11, 2011/12 Mortality from epilepsy under 75 per 100,000 population 2009-11 % of patients with epilepsy on drug treatment and convulsion free 18+ _____________________________________________________________ Respiratory % asthma prevalence 2010/11 Chronic obstructive pulmonary disease prevalence 2010/11 Spend on secondary care admissions per 1000 population 2010/11 Spend on elective and day-case admissions per 1000 population Spend on non-elective admissions per 1000 population Spend on FHS prescribing per 1000 population Secondary care admissions per 1000 population Elective and day-case admissions per 1000 population Non-elective admissions per 1000 population Emergency COPD Admissions per 100 Patients on Disease Register Mortality from asthma under 75 per 100,000 population 2009-11 Mortality from bronchitis, emphysema, and COPD under 75 per 100,000 population 2009-11 Mortality from bronchitis and emphysema under 75 per 100,000 population 2009-11 Reported prevalence of COPD on GP registers as a % of estimated prevalence