NHS RightCare Intelligence CCG Focus Pack

February 2019

00RBlackpool

NHS RightCare IntelligenceCCG Focus Pack- Gastrointestinal conditions

February 2019

Blackpool

PLEASE NOTE THAT THIS IS A DRAFT PACK AND HAS NOT YET BEEN SIGNED OFF.

PLEASE DO NOT CIRCULATE THIS PACK WIDELY AND NOTE THAT IT IS SUBJECT TO CHANGE.

ANY AMENDMENTS FOLLOWING THE SIGN-OFF PROCESS WILL BE COMMUNICATED TO DELIVERY

PARTNERS.

ContentsIntroduction and Executive Summary…........................................................................................................................................ p.5

Section One: Pathways on a page….......................................................................................................................................... p.13Liver disease....................................................................................................................................................................... p.14Groin hernia........................................................................................................................................................................ p.18Upper gastrointestinal conditions........................................................................................................................................ p.21

Section Two: Overall spend on Problems of the Gastrointestinal System - Programme Budgeting Dataset.............................. p.24

Section Three: Risk factors and prevention................................................................................................................................ p.30

Section Four: Primary care prescribing....................................................................................................................................... p.45Programme level indicators..................................................................................................................................................p.47BNF chapters...................................................................................................................................................................... p.50Proton pump inhibitors........................................................................................................................................................ p.53Laxatives............................................................................................................................................................................. p.71Stoma care.......................................................................................................................................................................... p.79

Section Five: Referral to treatment waiting times........................................................................................................................ p.89

Section Six: Outpatient spend and attendances......................................................................................................................... p.92

Section Seven: Programme and condition level inpatient spend.............................................................................................. p.106Condition level inpatient spend – Programme budgeting categories................................................................................ p.107Upper gastrointestinal problems - Elective spend............................................................................................................. p.114Lower gastrointestinal problems - Elective spend............................................................................................................. p.119Hepatobiliary problems – Elective spend.......................................................................................................................... p.124Other gastrointestinal problems - Elective spend.............................................................................................................. p.129Upper gastrointestinal problems - Non-elective spend...................................................................................................... p.134Lower gastrointestinal problems - Non-elective spend...................................................................................................... p.139Hepatobiliary problems - Non-elective spend.................................................................................................................... p.144Other gastrointestinal problems - Non-elective spend...................................................................................................... p.149

Contents continued

Emergency gastroenteritis admissions.......................................................................................................................... p.154

Section Eight: Inflammatory bowel disease........................................................................................................................... p.158

Section Nine: Procedures...................................................................................................................................................... p.175Endoscopies................................................................................................................................................................... p.177Cholecystectomies......................................................................................................................................................... p.209Hernias........................................................................................................................................................................... p.226Bowel resections............................................................................................................................................................ p.239Oesophageal varices procedures, paracentesis and liver transplants .......................................................................... p.248Appendicectomies.......................................................................................................................................................... p.259Haemorrhoid and other lower gastrointestinal procedures............................................................................................ p.267

Section Ten: Outcomes.......................................................................................................................................................... p.273

Annex..................................................................................................................................................................................... p.275

Equality and health inequalities

Promoting equality and addressing health

inequalities are at the heart of NHS England’s

values. Throughout the development of the policies

and processes cited in this document, we have:

• Given due regard to the need to eliminate

discrimination, harassment and victimisation, to

advance equality of opportunity, and to foster

good relations between people who share a

relevant protected characteristic (as cited under

the Equality Act 2010) and those who do not

share it; and

• Given regard to the need to reduce inequalities

between patients in access to, and outcomes

from, healthcare services and to ensure services

are provided in an integrated way where this

might reduce health inequalities.

Information governance statement

Organisations need to be mindful of the need to

comply with the Data Protection Act 1998, the

Common Law Duty of Confidence and Human

Rights Act 1998 (Article 8 – right to family life and

privacy).

This information can be made available in

alternative formats, such as easy read or large

print, and may be available in alternative

languages, upon request. Please contact 0300 311

22 33 or email [email protected] stating

that this document is owned by NHS RightCare.

NHS England Information Reader Box

Text to be provided by Gateway during publication process.

mailto:[email protected]

• NHS South Sefton CCG

• NHS Knowsley CCG

• NHS South Tyneside CCG

• NHS South Tees CCG

• NHS North East Lincolnshire CCG

• NHS Thanet CCG

• NHS St Helens CCG

• NHS Halton CCG

• NHS Sunderland CCG

• NHS Stoke on Trent CCG

Your gastrointestinal intelligence pack

Welcome to your intelligence pack on problems of the gastrointestinal

system. Information contained in this pack is personalised for your CCG

and should be used to support local discussions and inform a more in-depth

analysis around gastrointestinal services.

This pack provides detailed information on the opportunities to improve

gastrointestinal services, although the range of nationally available outcome

and quality indicators is limited in this area. Your CCG should work with

your local health system and clinical leads to understand the value you are

getting for the money you spend, and discuss next steps.

By using this information, together with local intelligence and reports, your

CCG will be able to ensure its plans focus on those opportunities which

have the potential to provide the biggest improvements in health outcomes,

resource allocation and reducing inequalities.

The data in the pack shows your CCG compared to the 10 most

demographically similar CCGs. This is used to identify realistic

opportunities to improve health and healthcare for your population.

Your 10 most similar CCGs are:

Next steps and actions

Local health systems can take the following actions now:

Identify the key opportunities for improvement shown in the pack

and compare with current reform activity and improvement plans.

Engage with clinicians and other local stakeholders to explore the

opportunities further, using regional and local data.

Discuss the opportunities highlighted in the pack as part of the STP

planning process.

Speak to your NHS RightCare Delivery Partner and your regional

team about other practical steps for your locality.

A clinical perspective

“The NHS RightCare Intelligence resources and the wider NHS RightCare approach place the NHS at the forefront of addressing unwarranted variation in care, improving patient outcomes and making our resources go as far as possible. NHS RightCare has a bank of evidence regarding what works, what’s replicable to share with systems and to scale up across the country. NHS RightCare uses robust, nationally collected data, and works in partnership with health systems to make improvements in patient outcomes by identifying opportunities and priorities, leading to improvements in spend.

“These Intelligence packs shine a light on what we are doing across the country, identifying areas of greatest opportunity. The NHS RightCare approach uses a systematic methodology for quality improvement, led by clinicians, for the benefit of all. This amazing resource allows all health professionals, managers and their partner organisations to explore the information and use it to support local discussions to agree a starting point for change. In this way we can deliver the best possible care in the most effective way for our patients.”

Professor Nick Harding OBE, Senior Clinical Advisor, NHS RightCare

Your headline data

For the published Gastrointestinal Focus Packs, this slide will contain CCG headline data. This will include indicators where your CCG

has large potential opportunities, alongside data on areas which all local health systems should consider. These have been agreed with

clinical stakeholders, and further information on them is provided below:

• Liver disease is the only major cause of death increasing year-on-year in the UK. This contrasts strongly to other European countries where

mortality rates are decreasing, and it is estimated that over 90% of liver disease is preventable. See pages 14-17 for further information.

• Upper GI and colon cancer is rare in under 45s. This means many endoscopy referrals for this age group are inappropriate. NICE guidance

recommends faecal calprotectin testing to aid the diagnosis of inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS) where cancer

is not suspected, and the Faecal Immunochemical Test (FIT) for those at low risk of bowel cancer. See pages 177-208 for further information.

• Nationally, there is wide variation in the management of patients with gallstone related diseases. NICE guidance states that adults with acute

cholecystitis should have laparoscopic cholecystectomy within one week of diagnosis, but patients regularly have to wait much longer to receive

the procedure. See pages 209-225 for further information.

What’s in your gastrointestinal pack

The following information is included in the detailed

gastrointestinal focus pack:

• Pathways on a page

• Risk factors / prevalence

• Primary care prescribing

• Referral to treatment waiting times

• Inpatient admissions

• Inpatient procedures

• Outcomes

• Procedure, diagnosis and drug codes and descriptions

• Useful links

• Metadata

The NHS RightCare approach

NHS RightCare teams work locally with systems to present a diagnosis of

data and evidence across that population. NHS RightCare Delivery

Partners and their teams work collaboratively with systems to look at the

evidence to identify opportunities.

Using nationally collected robust data, this collaborative working

arrangement helps systems make improvements in both spend and

patient outcomes.

Throughout the process patient care is kept at the top of agenda by

promoting the strong clinical interventions developed with senior clinical

advisors and relevant stakeholders.

Further information

NHS RightCare tools, methodology and full details of all the data used in this pack are available on the Intelligence pages of the NHS

RightCare website at https://www.england.nhs.uk/rightcare/products/

If you have any questions about this pack or require any further information and support you can email the Intelligence team directly at

[email protected]

For more general information about how to use the NHS RightCare approach to get best value for your population, visit

www.england.nhs.uk/rightcare, email [email protected] or tweet @nhsrightcare. You can also sign up to the NHS RightCare bulletin for

regular updates on new products and tools.

https://www.england.nhs.uk/rightcare/products/


https://www.england.nhs.uk/rightcare/


https://twitter.com/nhsrightcare

https://www.england.nhs.uk/email-bulletins/nhs-rightcare-bulletin/

Gastrointestinal conditions – A clinical introduction Gastrointestinal symptoms are very common and account for 10% of all GP consultations. In 2017/18, CCG expenditure on digestive problems was £4.45 billion across primary and secondary care.

Functional disorders (such as irritable bowel syndrome, heartburn and haemorrhoids) are commonly the cause, but in older patients, similar symptoms may be due to cancer. In fact, cancers of the digestive tract and liver are the leading cause of cancer death (26% of cancer deaths). How to diagnose and optimally manage this broad range of common conditions is considered in 24 NICE guidance publications.*

Large scale opportunities exist for systems looking to improve the healthcare delivered to their populations, which cut across the diverse range of digestive disorders, including:

• Simple first line diagnostic testing (blood and stool tests) to support appropriate continued management of patients in primary care.

• Improving the quality and appropriateness of referrals to secondary care, especially for direct access to diagnostic endoscopy, which has the potential to free up capacity across the system and aid early detection of cancer and other chronic disease, such as inflammatory bowel disease.

• For conditions which need surgical treatment (such as hernia repair and cholecystectomy) ensuring patients receive timely accessto procedures.

• Deaths from liver disease are the only major cause of death that is still increasing year on year in the UK, but >90% is preventable by working with public health and other bodies to improve prevention, detection and management of patients at risk of cirrhosis due to alcohol abuse, obesity and Hepatitis C.

Further information on commissioning evidence-based care for Patients with Gastrointestinal and Liver Disease has been provided by the British Society of Gastroenterology (2012).

Dr Robert Logan, Consultant Gastroenterologist and National Clinical Advisor for Endoscopy, NHS England

* Data and information on GI cancers are published separately as part of NHS RightCare Cancer Focus Packs

https://www.bsg.org.uk/clinical/clinical-services/evidence-based-care-for-gi-and-liver-patients.html

National average

Your potential opportunity - the difference to your peer group benchmark: “Best or lowest 5” or “Highest 5” or “Similar 10”

Interpreting the Chart -National distribution chart

For SUS spend indicators only, your equivalent potential activity opportunity

Your CCG

Nat

ion

alC

CG

dis

trib

uti

on

Your similar 10 CCGs

Your peer group benchmark: “Best or lowest 5” or “Highest 5” or “Similar 10”

Your CCG

Further guidance on interpreting national distribution charts

Top chart: Shows the whole England distribution of CCGs together with the highlighted Similar 10 CCG group (grey columns)

and your CCG (yellow column). The England value and the peer group benchmark values based are shown below this chart.

Opportunity box: Potential opportunities are calculated and shown in the top right of chart. These can be calculated against

the average of the lowest or highest five CCGs in a similar 10, or the similar 10 average. In cases when an indicator is RAG

rated, the lowest or highest five average is labelled the “the best 5”. The following gives more information on how to interpret the

assigned colour shown in these boxes:

Red = Statistically significantly worse than best 5 and quantified CCG opportunity

Amber & ‘amount (NSS)’ = Not statistically significant - worse than best 5

Amber & ‘blank’ = Not statistically significant – better than best 5

Blue = For indicators where the lowest 5 average is used, potential opportunities are only shown where the CCG is higher than

this benchmark. For indicators where the highest 5 average is used, potential opportunities are only shown where the CCG is

lower than this benchmark. For indicators where the average of the 10 CCGs is used, potential opportunities are only shown

where the CCG is higher than this benchmark. All opportunities in blue Opportunity boxes require local interpretation.

Green = Statistically significantly better than best 5

Blank (white) = No CCG data, or the data have been supressed due to small numbers.

Grey = Unable to calculate benchmark due to similar CCGs having no data.

For SUS spend indicators only, your equivalent activity opportunity will be shown in a second box. For more information on how

these are calculated, please see pages 277-280.

Please note: A star (*) in the opportunity box indicates that no improvement opportunities have been calculated for an indicator.

Information on the reason for this will be provided in the text underneath the bottom chart.

Bottom chart: Shows your CCG and the Similar 10 CCG group together with their indicator values. The peer group benchmark

is shown by the dark blue line. The source is shown at the bottom left.

Interpreting the Chart -

Your CCG

Interpreting the Chart -Blue and yellow bar chart

Your potential opportunity - the difference to your peer group benchmark: “Best or lowest 5” or “Highest 5” or “Similar 10”

Your peer group benchmark:“Best or lowest 5” or “Highest 5” or “Similar 10”

Opportunities that are not statistically significant (as indicated by the error bars crossing the benchmark) are labelled with (NSS)

13

Section One: Pathways on a page

14

Liver disease

15

Liver disease: Overview

Liver disease is one of the most common causes of premature death in the UK. It is the only major cause of death which is still increasing year-on-year.

This contrasts strongly to other European countries, where mortality rates are decreasing. In 2012, the Chief Medical Officer for England, in their Annual Report, identified liver disease as one of the three key issues for population health because it was ‘the only major cause of mortality and morbidity which is on the increase in England whilst decreasing among our European neighbours’.

90% of liver-related deaths occur in people under the age of 70. Liver disease is now the fourth most common cause of years of life lost in England, with 62,000 years of working life lost to the disease every year.

Comparative UK mortality rates

Graph: Data sourced from the Lancet Liver Campaign report: Addressing liver disease in the UK

(Data were normalised to 100% in 1970, and subsequent trends plotted using the software Statistical Package for the Social Sciences. Data are from the WHO-HFA database.4 Analysed by Nick Sheron September, 2013).

16

Liver disease: Risk factors and further resources

It has been estimated that over 90% of liver disease is preventable. Despite this, the three main causes of liver disease – alcohol-related liver disease, fatty liver disease and viral hepatitis – continue to affect increasing numbers of people.

There is a strong correlation between deprivation and mortality from liver disease. Many patients who die from liver disease come from particularly marginalised groups such as the homeless and those with an alcohol and/or drug dependency.

Integrated care is crucial for effective prevention and management of liver disease, being so closely linked into public health and health inequalities. Recognising, treating and managing patients with viral hepatitis and alcohol dependency in particular, requires commissioners, local authorities (Directors of Public Health), health and wellbeing boards, clinicians and providers of primary care, secondary care and public health services to work in close partnership with each other.

Useful links and resources:

PHE Liver Disease Atlas of Variation: https://fingertips.phe.org.uk/profile/atlas-of-variation

PHE Liver Disease Profiles:https://fingertips.phe.org.uk/profile/liver-disease/data#page/0

HCVAction Hepatitis C adult services commissioning toolkit: http://www.hcvaction.org.uk/resource/hepatitis-c-adult-services-commissioning-toolkit

The Lancet Liver Campaign: https://www.thelancet.com/campaigns/liver?utm_source=email&utm_medium=LiverEM1&utm_campaign=liver

British Liver Trust/Royal College of General Practitioners Liver Disease Toolkit:http://www.rcgp.org.uk/clinical-and-research/resources/toolkits/liver-disease-toolkit.aspx

The Scarred Liver Pathway in Nottinghamshire:https://nhsaccelerator.com/understanding-nhs-adopts-innovation-scarred-liver-pathway-nottinghamshire/

https://fingertips.phe.org.uk/profile/atlas-of-variation

https://fingertips.phe.org.uk/profile/liver-disease/data

http://www.hcvaction.org.uk/resource/hepatitis-c-adult-services-commissioning-toolkit

https://www.thelancet.com/campaigns/liver?utm_source=email&utm_medium=LiverEM1&utm_campaign=liver

http://www.rcgp.org.uk/clinical-and-research/resources/toolkits/liver-disease-toolkit.aspx

https://nhsaccelerator.com/understanding-nhs-adopts-innovation-scarred-liver-pathway-nottinghamshire/

NHS Blackpool CCG

17

Liver disease pathway

Please note: % of eligible persons completing a course of hepatitis B vaccination and Hepatitis C detection rate indicators have been produced by mapping Local Authority data to CCG level. Elective spend, non-elective spend

and mortality indicators align with PHE's definition of liver disease, which includes admissions and deaths due to liver cancer.

Many cases of liver cancer are linked to cirrhosis. Cirrhosis is commonly caused by heavy and harmful drinking, hepatitis C and the build-up of fat inside the tissue of the liver. Liver cancer incidence is therefore related to a

number of other indicators in the pathway, meaning CCGs have been rated better/worse than their similar peers.

-40%

-20%

0%

20%

40%

60%

80%

100%

120%

ObesityPrevalence, 16+

Alcohol-specificadmissions

Emergencyalcohol-specific

readmissions

% of eligiblepersons

completing acourse of

hepatitis Bvaccination

Hepatitis Cdetection rate

Paracetamoloverdose

admissions

Rate added toliver transplant

waiting list

Liver transplantrate

Elective spend Non-electivespend

Alcohol relatedliver diseaseadmissions

% paracentesisprocedures

performed asemergencies

Liver cancerincidence

<75 mortality

2017/18 2017/18 2015/16 -2017/18

2016/17 2016 2017/18 2012/13 -2017/18

2012/13 -2017/18

2017/18 2017/18 2017/18 2017/18 2014-16 2016

% d

iffe

ren

ce f

rom

Sim

ilar

10

CC

Gs

Better Worse Needs local interpretation

If no bar and error bars are displaying for an indicator, this is due to the CCG values being suppressed. Full metadata for all of the above indicators can be found in the excel datafile for this pack which can be requested from [email protected]


18

Groin hernia

19

Inguinal hernia

Inguinal hernias (commonly referred to as groin hernias) occur in the groin, most frequently affect men and are the most common type of hernia. The hernia usually occurs when a weakness in the abdominal wall allows fatty tissue or a part of the bowel to protrude into the inguinal canal.

The surgical repair of inguinal hernias make up around 70% of all diagnosed hernias and is one of the most common procedures undertaken in secondary NHS care. In 2016/17 there were 78,733 inguinal hernia procedures carried out in hospitals in England, an increase of 0.8% from 2015/16.

The Royal College of Surgeons has published a Hernia Commissioning Guide (2016) that includes referral guidelines for primary care. They state that CCGs should not set criteria for referral and treatment for inguinal hernias outside the recommendations within the guide, as this approach produces worse clinical outcomes and has not been shown to be cost effective.

Although asymptomatic hernias can be managed conservatively by taking a watch and wait approach there is a likelihood that surgery will be required in the future. This option should be taken after a consultation with a hernia surgeon. The Royal College of Surgeons, in a joint report with the British Hernia Society, has stated that using the watch and wait approach leads to poorer outcomes for patients and is not cost effective for the health system as a whole. Referring to a cohort study published in 2014, they reveal that patients undergoing this approach compared with elective repair were:

• 59% more likely to require an emergency repair

• At an increased risk of adverse events (18.5% compared to 4.7%)

• At an increased risk of mortality (5.4% compared to 0.1%)

This joint report, A dangerous waiting game? A review of patient access to inguinal hernia surgery in England (June 2018),sets out the scale of CCG restrictions, the impact these are having on patients, and what needs to be done at a local and national policy level to address this.

https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/hernia--commissioning-guide.pdf

https://www.rcseng.ac.uk/-/media/files/rcs/news-and-events/media-centre/rcs--bhs-hernia-report-june-2018.pdf

NHS Blackpool CCG

20

Groin hernia pathway

-40%

-20%

0%

20%

40%

Smoking prevalence, 18+ % primary repairs ofinguinal hernia performed

as a day case

% primary repairs ofinguinal hernia performed

laparoscopically

% bilateral primary repairsof inguinal hernia

performed laparoscopically

Primary repair of inguinalhernia - 30 day all-causeemergency readmissions

Primary repair of inguinalhernia - Elective spend

Inguinal hernia - Non-elective admissions

Primary repair of inguinalhernia - Non-elective spend

Repair of recurrent inguinal hernia – Total spend

2017/18 2017/18 2017/18 2015/16-2017/18 2016/17 - 2017/18 2017/18 2017/18 2017/18 2017/18

% d

iffe

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ce f

rom

Sim

ilar

10

CC

Gs




21

Upper gastrointestinal conditions

22

Upper gastrointestinal conditions pathway

The following pathway on a page focusses on upper gastrointestinal conditions.

Risk factor (smoking prevalence, alcohol-specific hospital admissions and re-admissions), primary care (proton pump inhibitor expenditure) and secondary care (diagnostic gastroscopy activity and waiting times) indicators contribute to or are used to treat and diagnose a range of upper GI conditions. The percentage of prescribing patients at increased risk of a GI bleed is taken from the NHS Business Service Authority'sMedication Safety dashboard, further information on which can be found on pages 62-66 and pages 68-69 of this pack.

As the two conditions which do the most to drive upper GI non-elective spend and activity, non-elective admission and re-admission indicators for gastrointestinal bleeding and peptic ulcers are included towards the end of the pathway. The final indicator is for non-elective spend on all conditions which map to the upper GI programme budgeting category.

The pathway has been developed from the version which previously appeared in the RightCare 2016 Where to Look packs. Following stakeholder feedback, the lower GI pathway which also featured in this publication is not included in this focus pack. It is aimed that future publications will include an updated version of this pathway, which will focus on a more specific set of lower GI conditions.

NHS Blackpool CCG

23

Upper gastrointestinal conditions pathway

-80%

-60%

-40%

-20%

0%

20%

40%

Smokingprevalence, 18+

Alcohol-specificadmissions

Emergencyalcohol-specific

readmissions

Prescribingpatients at

increased risk ofGI bleed

Proton pumpinhibitors - Spend

Diagnosticgastroscopies -Day case and

outpatientactivity

Diagnosticgastroscopies -Day case and

outpatientactivity (<45s)

Waiting listpatients waiting>6 weeks for a

gastroscopy

Elective spend Non-electivegastroscopyadmissions

GI bleeds - Non-elective

admissions

Peptic ulcers -Non-electiveadmissions

Peptic ulcers - 30day all-causeemergency

readmissions

Non-electivespend

2017/18 2017/18 2015/16 -2017/18

2017/18 Q4 2017/18 2017/18 2017/18 2017/18 (4separate months

combined)

2017/18 2017/18 2017/18 2017/18 2016/17 -2017/18

2017/18

% d

iffe

ren

ce f

rom

Sim

ilar

10

CC

Gs



Please note: Gastroscopies are one of 15 key diagnostic tests which the NHS Constitution states less than 1% of patients should wait more than 6 weeks for. CCGs which achieve good performance compared to their peers may still be missing this target. CCGs are therefore advised to examine their waiting list times in greater detail, which are available at: https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity


https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/

24

Section Two: Overall spend on problems of the gastrointestinal system - programme budgeting dataset

25

Overview of the NHS programme budgeting expenditure dataset

The programme budgeting dataset provides an analysis of a CCG’s total expenditure by programmes of care based on disease classifications. There are 23 main classifications and these are known as programme budgeting categories (PBCs). Problems of the gastrointestinal system is PBC 13, and this is further classified into the following subcategories:

13a: Problems of the Upper Gastrointestinal System13b: Problems of the Lower Gastrointestinal System13c: Problems of the Hepatobiliary System13x: Other problems of the Gastrointestinal System

As well as providing condition level expenditure, the data is also split by ‘care setting’. Examples of care settings includeprimary care prescribing, elective admissions, outpatient attendances etc. The programme budgeting dataset included 13 care settings in 2017/18.

Within the programme budgeting benchmarking tool the care settings are classified as either ‘care settings recommended for benchmarking’ or ‘other care settings’. ‘Care settings recommended for benchmarking’ are those in which expenditure can be reliably compared, as the underlying data sources and calculation methodologies are consistent across organisations. The ‘other care settings’ are not recommended for benchmarking as any variation may be due to by differences in data source or calculation methodology.

The dataset contains programme level expenditure data as reported by CCGs, rather than taken from central datasets. This means that it includes adjustments for local variations to national prices, contract penalties and best practice tariffs not processed through the Secondary Uses Service (SUS). The data therefore provide a useful opportunity for triangulation against SUS indicators derived from the National Commissioning Data Repository (NCDR), which are calculated using activity combined with national prices.

The aim of the dataset is to eventually provide health condition group level expenditure which can be used for benchmarking across the whole care pathway.

26

Comparing inpatient spend data derived from NCDR data and the programme budgeting datasetStarting from page 107, two inpatient spend indicators have been produced for the GI main category and each subcategory; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting data set.

Opportunities have not been calculated for programme budgeting indicators. They are provided to support further investigationinto how the spend data is affected when local pricing arrangements are applied.

The table below provides information on the differences between inpatient spend indicators derived directly from NCDR and those derived from the CCG programme budgeting dataset.

27

Programme budgeting expenditure dataset: Charts for problems of the gastrointestinal system

This pack includes the following indicators derived from the CCGs Programme Budgeting Dataset:

• Aggregate expenditure on care settings recommended for benchmarking – see page 29.• Outpatient expenditure (for attendances and procedures in scope of national tariff) – see page 95.• Inpatient expenditure (for all elective and non-elective admissions in scope of national tariff) - see page 109.• Inpatient expenditure on elective admissions (in scope of national tariff) - see page 111.• Inpatient expenditure on non-elective admissions (in scope of national tariff) – see page 113.

The aggregate expenditure on care settings recommended for benchmarking chart includes spend in the following care settings:

• Primary care prescribing• Non-elective admissions (in National tariff scope)• Elective admissions (in National tariff scope)• Outpatient attendances (in National tariff scope)• Outpatient procedures (in National tariff scope)• Critical care• Drugs and devices

The following care settings are not currently recommended for benchmarking and have been excluded from this pack:

• Accident and emergency• Emergency transport• Outpatient activity (outside of National tariff scope)• Other inpatient (outside of National tariff scope)• Other health care services• Running costs

NHS Blackpool CCG

28

0%

5%

10%

15%

20%

25%

30%

35%

40%

Primary CarePrescribing

Non-electiveadmissions

A&E* EmergencyTransport*

Elective OutpatientAttendances (inNational Tariff

Scope)

OutpatientProcedures (inNational Tariff

Scope)

OutpatientActivity (outsideof National Tariff

Scope)*

Critical Care Drugs & devices Other Inpatient(outside of

National TariffScope)*

Other HealthCare Services*

% split for NHS Blackpool CCG % split for CCG similar 10

% o

f E

xp

en

ditu

re in s

ele

cte

d P

rogra

mm

e c

ate

go

rySpend in care setting as % of total spend on problems of the gastrointestinal system (PB dataset) - 2017/18

The programme budgeting dataset provides CCG estimates of expenditure on Problems of the Gastrointestinal System (PBC13) across the pathway. This chart provides information on which types of activity are driving expenditure in PBC13 for your CCG and how this compares to your similar 10 CCGs. It provides an overarching view of spend patterns which can be used to identify areas for further investigation. Average of the similar 10 has been used to provide a comparison to a constant group of CCGs across all care settings, so that the CCG can see where they are relatively low or high across the pathway. The average of the lowest 5 similar CCGs has not been used for individual care settings because this would tend to show the CCG to be generally higher across all settings.

Columns marked with an asterisk are the care settings not recommended for benchmarking (for more information on programme budgeting dataset care settings please see page296).

*

Figures are taken from the 2017/18 CCG Programme Budgeting Expenditure Dataset. This is calculated using CCG self-reported spend and includes adjustments for local pricing

and contracting arrangements. Services commissioned directly by NHS England are not included. Data are available for all 207 CCGS which existed in 2017/18. Figures have been

amended for some organisations to create estimates which reflect the 2018/19 CCG structures. For more information on the calculation of programme budgeting dataset, please

refer to pages 295 to 298.

29

Gastrointestinal problems (PBC 13) - Care Settings recommended for

benchmarking spend per 1,000 overall weighted population (PB dataset) - 2017/18

NHS Blackpool CCG

Source: 2017/18 Programme Budgeting dataset

64,274 65,005 76,835 78,526 78,559 79,121 79,409 80,498 80,880 82,677 83,967

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

Blackpool Stoke on Trent Sunderland North EastLincolnshire

Thanet South Tyneside South Tees Halton St Helens Knowsley South Sefton

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Other CCGs Blackpool Similar 10 National Best or Lowest 5

England Best or Lowest 572,616 75,609

Section three: Risk factors and prevention

31

Clostridium difficile infections

https://support.office.com/en-us/article/Work-with-hyperlinks-in-Excel-7fc80d8d-68f9-482f-ab01-584c44d72b3e

32

Clostridium difficile (C. difficile)

Clostridium difficile is a bacterium that can infect the bowel and cause diarrhoea. In some cases serious complications can develop, such as damage to the bowel or severe dehydration, which may cause drowsiness, confusion, a rapid heart rate and fainting.

Many C. difficile infections used to occur in places where many people take antibiotics and are in close contact with each other, such as hospitals and care homes. However, strict infection control measures have helped to reduce this risk, from 55,498 cases in 2007/08 to 13,286 cases in 2017/18 (Annual Epidemiological Commentary 2018) and an increasing number of C. difficile infections now occur outside these settings.

Who is at risk?

• Advanced age — the rate of positive C. difficile assay results in people older than 65 years of age is 20–100 times greater than the rate in people 10–20 years of age.

• Antibiotic treatment — although none can be excluded, the most commonly implicated antibiotics are clindamycin, cephalosporins — in particular second- and third-generation cephalosporins, fluoroquinolones (such as ciprofloxacin, norfloxacin), co-amoxiclav, ampicillin and amoxicillin.

• Underlying morbidity such as abdominal surgery, cancer, chronic renal disease, and tube feeding.

• Current use of a proton pump inhibitor (such as omeprazole and lansoprazole) or other acid reflux relief drugs (such as H2-receptor antagonists).

Public Health England publishes annual data on rates of C. difficile infections by acute trust and CCG in patients aged two years and over. They also produce guidance on the most effective methods of prevention and control of C. difficile infection.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/724030/Annual_epidemiological_commentary_2018.pdf

https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data

*

Note that this indicator uses crude instead of standardised rates, and so differences in population structures are uncontrolled. For this reason, although the indicator has been

RAG rated no opportunities have been calculated.

33

Total C. difficile infection rates per 100,000 population - 2017/18

NHS Blackpool CCG

Source: Reported C. difficile cases reported by trusts, attributed to CCGs by NHS Digital Demographics Batch Service (DBS) and Organisation Data Service (ODS)

45

21 25 26 26 27 28 31 32 34 34

-

10

20

30

40

50

60

North EastLincolnshire

Halton South Tyneside Stoke on Trent Thanet South Sefton Knowsley Sunderland St Helens South Tees Blackpool

-

10

20

30

40

50

60

70


England Best or Lowest 524 25

*

Note that this indicator uses crude instead of standardised rates, and so differences in population structures are uncontrolled. For this reason, although the indicator has been

RAG rated no opportunities have been calculated.

34

Community onset C. difficile infection rates per 100,000 population - 2017/18

NHS Blackpool CCG

Source: Reported C. difficile cases reported by trusts, attributed to CCGs by NHS Digital Demographics Batch Service (DBS) and Organisation Data Service (ODS)

32

8 12 15 16 16

20 22 22 24 24

-

5

10

15

20

25

30

35

40

45

50


South Sefton Halton South Tyneside Stoke on Trent Thanet Sunderland Knowsley St Helens South Tees Blackpool

-

10

20

30

40

50

60



Other gastrointestinal risk factors and prevention

*

No opportunities have been calculated for prevalence indicators.

NICE Obesity Guidance: https://www.nice.org.uk/guidance/conditions-and-diseases/diabetes-and-other-endocrinal--nutritional-and-metabolic-conditions/obesity#pathways

36

Reported prevalence of patients aged 18 or over with a BMI ≥30 in the preceding 12 months - 2017/18

NHS Blackpool CCG

Source: Quality and Outcomes Framework (QOF), NHS Digital

13.2

9.611.5 11.7 12.0 12.0 12.8 13.3 13.9 14.2 14.7

-

2

4

6

8

10

12

14

16

Thanet South Sefton St Helens South Tees North EastLincolnshire

Knowsley Blackpool Sunderland South Tyneside Halton Stoke on Trent

-

2

4

6

8

10

12

14

16

18


England Best or Lowest 59.8 11.4

*

Bariatric surgery can improve quality of life and reduce the risk of premature mortality for selected individuals with severe and complex obesity (criteria, reflecting clinical and

cost effectiveness, outlined in: https://www.nice.org.uk/guidance/qs127/resources/obesity-clinical-assessment-and-management-pdf-75545363615173 and

https://www.nice.org.uk/guidance/cg189/resources/obesity-identification-assessment-and-management-pdf-35109821097925). While such guidelines allow estimation of

numbers of people that would fulfil the outlined criteria, other factors, such as patient preference and shared decision making, make derivation of an optimum activity rate for

bariatric surgery more challenging, and so this indicator has not been RAG rated, a similar 10 benchmark used and no opportunities calculated. CCGs with low activity rates,

however, may wish to consider increasing access to bariatric surgery.

37

Bariatric surgery - Admissions where obesity is the primary diagnosis per 100,000 age-sex weighted

population - 2017/18

NHS Blackpool CCG

Source: National Commissioning Data Repository (NCDR) – Hospital Admissions Databases, SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart)

4 6 9 9

30 36

-

5

10

15

20

25

30

35

40

45

50

South Tyneside Sunderland Blackpool South Sefton St Helens Knowsley Halton Thanet North EastLincolnshire

South Tees Stoke on Trent

-

10

20

30

40

50

60

Other CCGs Blackpool Similar 10 National Similar 10

No Data No Data No Data No Data No Data

England Similar 1010 16

*

No opportunities have been calculated for prevalence indicators.

NICE Smoking and Tobacco Guidance: https://www.nice.org.uk/guidance/lifestyle-and-wellbeing/smoking-and-tobacco#pathways

38

Percentage of people aged 18+ who are self-reported occasional or regular smokers - 2017/18

NHS Blackpool CCG

Source: GP Patient Survey

21.9

14.2 15.3 15.5 16.7 16.8 16.8 17.1 17.8 19.0 20.3

-

5

10

15

20

25

St Helens Sunderland South Sefton South Tyneside Halton South Tees Stoke on Trent Thanet Knowsley North EastLincolnshire

Blackpool

-

5

10

15

20

25

30

35



756

People

Note that that this indicator has been produced by mapping Local Authority data to CCG level.

NICE Smoking and Tobacco Guidance: https://www.nice.org.uk/guidance/lifestyle-and-wellbeing/smoking-and-tobacco#pathways

39

Smoking quit rates: Successful quitters per 100,000 smokers aged 16yrs+ - 2017/18

NHS Blackpool CCG

Source: Stop Smoking Services, NHS Digital

1,138 1,558

2,006 2,386 3,336 3,405 3,422 3,497

4,160 4,686 4,750

-

1,000

2,000

3,000

4,000

5,000

6,000

Blackpool Thanet North EastLincolnshire

Sunderland South Tyneside South Tees Halton South Sefton Stoke on Trent Knowsley St Helens

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000



136 Adms

NICE Quality Standard (Alcohol-use disorders: diagnosis and management): https://www.nice.org.uk/guidance/qs11

NICE Clinical Knowledge Summary (Alcohol - problem drinking): https://cks.nice.org.uk/alcohol-problem-drinking#!topicsummary

40

Rate of alcohol-specific admissions in people of all ages - Directly standardised rate per 100,000

Population - 2017/18

NHS Blackpool CCG

Source: Hospital Episode Statistics (HES) Admitted Patient Care (APC), provided by NHS Digital

211

85 102 127

155 198 200 202 221

268 302

-

50

100

150

200

250

300

350


Thanet South Tees Stoke on Trent South Tyneside Halton St Helens Blackpool Knowsley Sunderland South Sefton

-

50

100

150

200

250

300

350



NICE Quality Standard (Alcohol-use disorders: diagnosis and management): https://www.nice.org.uk/guidance/qs11

NICE Clinical Knowledge Summary (Alcohol - problem drinking): https://cks.nice.org.uk/alcohol-problem-drinking#!topicsummary

Please note: CCG values for this indicator are given as indirectly age sex standardised ratios, with the England value being 100.

41

Emergency alcohol-specific readmission to any hospital within 30 days of discharge following an alcohol-

specific admission - Indirectly age and sex standardised ratio - 2015/16 - 2017/18

NHS Blackpool CCG

Source: Hospital Episode Statistics (HES) Admitted Patient Care (APC), provided by NHS Digital

85 69

79 84 92 95 95 99 100 123 124

-

20

40

60

80

100

120

140

160

Thanet North EastLincolnshire

St Helens Blackpool Halton Knowsley Stoke on Trent South Tyneside South Tees Sunderland South Sefton

-

50

100

150

200

250

300



69 Adms

Taken in too high a dose, paracetamol can be dangerous and can cause fatal liver disease. See pages 128-133 of the 2017 Liver Disease Atlas of Variation for more information:


42

Paracetamol overdose - Admissions per 100,000 age-sex weighted population - 2017/18

NHS Blackpool CCG


115

53 55 56

93 110 113 115 119 122 127

-

20

40

60

80

100

120

140

160

Sunderland Thanet North EastLincolnshire

South Tyneside St Helens Halton South Sefton Blackpool Stoke on Trent South Tees Knowsley

-

20

40

60

80

100

120

140

160

180



*

Note that this indicator has been produced by mapping Local Authority data to CCG level. Persons who inject drugs are at higher risk of contracting hepatitis B and C infections.

Clients with a missing hepatitis B intervention status are assumed to be eligible and clients with a missing hepatitis B vaccination status are assumed not to have completed a

course of vaccinations. Completion for these fields is very high nationally but this may differ at a Local Authority level, from which this indicator is mapped. For these reasons, a

highest 5 benchmark is used for this indicator, but it is not RAG rated and no opportunities are calculated. See pages 97-114 of the 2017 Liver Disease Atlas of Variation for a

broader range of hepatitis B indicators: https://fingertips.phe.org.uk/profile/atlas-of-variation

43

Persons entering drug misuse treatment - % of eligible persons completing a course of hepatitis B

vaccination - 2016/17

NHS Blackpool CCG

Source: Public Health England, Fingertips (from National Drug Treatment Monitoring System (NDTMS) financial year submissions)

26.6

2.1 2.5 2.8 3.79.2

15.1

30.436.5

-

5

10

15

20

25

30

35

40

45

50

South Tyneside Thanet St Helens South Tees Sunderland South Sefton Stoke on Trent North EastLincolnshire

Blackpool Halton Knowsley

-

10

20

30

40

50

60

70

80

90

100

Other CCGs Blackpool Similar 10 National Highest 5

No Data No Data

England Highest 58.5 19.0

*

Note that this indicator has been produced by mapping Local Authority data to CCG level. Variation in detection rates may reflect differences in local testing activity for a given

population as well as the underlying population (e.g. larger proportion of risk groups, such as people who inject drugs). For this reason, this indicator has not been RAG rated, a

similar 10 benchmark used and no opportunities calculated. See pages 79-96 of the 2017 Liver Disease Atlas of Variation for a broader range of hepatitis C indicators:


44

Hepatitis C detection rate per 100,000 population - 2016

NHS Blackpool CCG

Source: Public Health England, Fingertips (from SGSS data (Second Generation Surveillance System) - Laboratory reporting. CIDSC, National Infection Service)

18

4 4 4 5 10

14 15

28 32

-

5

10

15

20

25

30

35

40

45

Halton South Sefton South Tyneside Knowsley Sunderland Thanet South Tees St Helens Blackpool Stoke on Trent North EastLincolnshire

-

50

100

150

200

250

300


No Data


45

Section four: Primary care prescribing

https://nhsengland.sharepoint.com/


46

NHS RightCare prescribing indicators and ePACT2

Indicators in the following section provide a summary of CCG prescribing spend, activity and performance for gastrointestinal conditions. In addition to these high-level indicators, CCGs can gain more detailed insights into their prescribing practices through the NHS Business Services Authority's ePACT2 application.

ePACT2 provides users with access to online analyses of prescribing data held by NHS Prescription Services. Data is available six weeks after the dispensing month, and so enables up to date analysis to be performed on CCG prescribing performance. Indicators on pages 62-66 and 68-69 of this pack have been taken from the Medication Safety dashboard, and other specific dashboards are available via ePACT2 to support interpretation of RightCare data.

For more information about ePACT2, please see: https://www.nhsbsa.nhs.uk/epact2

https://www.nhsbsa.nhs.uk/epact2

Gastrointestinal prescribing: Programme level indicators


£8k (NSS)

The above indicator is a very high-level measure, including all drugs which map to the GI programme budgeting category. For more information on how drugs have been mapped

to the gastrointestinal programme budgeting category, please see pages 295-298 of the pack annex. Indicators in the following sections will provide a more detailed view of CCG

prescribing spend and performance.

48

Primary Care Prescribing: Spend on Problems of the Gastrointestinal system per

1,000 ASTRO-PU weighted population - 2017/18

NHS Blackpool CCG

Source: NHS Business Services Authority

15,721 14,522 14,922 16,218 16,258 16,472 17,571 17,810 18,332 18,334 18,695

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000


Stoke on Trent Blackpool Thanet South Tyneside St Helens South Tees South Sefton Knowsley Halton Sunderland

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000



61k Items

The above indicator is a very high-level measure, including all drugs which map to the GI programme budgeting category. For more information on how drugs have been mapped

to the gastrointestinal programme budgeting category, please see pages 295-298 of the pack annex. Indicators in the following sections will provide a more detailed view of CCG

prescribing spend and performance.

49

Primary Care Prescribing: Problems of the Gastrointestinal system - Items per

1,000 ASTRO-PU weighted population - 2017/18

NHS Blackpool CCG


2,506

1,854 2,141 2,267 2,307 2,346 2,368 2,529 2,651 2,670

3,137

-

500

1,000

1,500

2,000

2,500

3,000

3,500


Stoke on Trent South Sefton Halton St Helens Blackpool South Tees South Tyneside Knowsley Sunderland

-

500

1,000

1,500

2,000

2,500

3,000

3,500



Gastrointestinal prescribing: British national formulary (BNF) chapters


51

GI prescribing - BNF chapters - Spend - 2017/18How different

are we?

NHS Blackpool CCG

574

1,472

1,982

2,030

143

264

1,006

198

159

458

6,375

451

1,167

1,956

1,843

92

350

881

174

206

592

5,875

£23k

£57k

£5k (NSS)

£36k

£9k

£24k

£4k

£94k

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

Dyspepsia andgastro-oesophageal reflux disease

Antispasmodics and other drugsaltering gut motility

Chronic bowel disorders

Proton pump inhibitors

Bulk forming laxatives

Stimulant laxatives

Osmotic laxatives

Local preparations for anal andrectal disorders

Drugs affecting biliarycomposition and flow

Pancreatin

Total stoma (BNF chapter 23)

Blackpool Best or lowest 5

per 1,000 ASTRO-PU weighted population (excluding PPIs, which are per 1,000 PPI STAR-PU weighted population)

CCG spend for 'Dyspepsia and gastro-oesophageal reflux disease' is mostly driven by alginic acid compounds, and does not include proton pump inhibitors. Also note that different models of providing stoma products other than GP FP10 prescribing are starting to be used by some CCGs. Stoma products not provided through FP10 are excluded from the above indicator, meaning data may not be directly comparable between similar CCGs and opportunity figures not realistic.Data for the above indicators is included in this pack's data file, which can be used to produce national distribution charts and perform local analysis. CCGs can access further information on the drug groups above via NICE BNF treatment summaries: https://bnf.nice.org.uk/treatment-summary/ Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

https://bnf.nice.org.uk/treatment-summary/

Note - opportunities won’t be shown when less than 500 items. 52

GI prescribing - BNF chapters - Items - 2017/18How different

are we?

NHS Blackpool CCG

103

156

72

1,450

30

121

200

26

4

11

109

83

110

64

1,202

19

103

161

21

5

11

115

4k Items

9k Items

2k Items

48k Items

2k Items

3k Items

8k Items

1k Items

0 200 400 600 800 1,000 1,200 1,400 1,600

Dyspepsia andgastro-oesophageal reflux disease

Antispasmodics and other drugs altering gut motility

Chronic bowel disorders


Bulk forming laxatives

Stimulant laxatives

Osmotic laxatives

Local preparations for anal andrectal disorders

Drugs affecting biliary compositionand flow

Pancreatin



per 1,000 ASTRO-PU weighted population (excluding PPIs, which are per 1,000 PPI STAR-PU weighted population)

CCG spend for 'Dyspepsia and gastro-oesophageal reflux disease' is mostly driven by alginic acid compounds, and does not include proton pump inhibitors. Also note that different models of providing stoma products other than GP FP10 prescribing are starting to be used by some CCGs. Stoma products not provided through FP10 are excluded from the above indicator, meaning data may not be directly comparable between similar CCGs and opportunity figures not realistic.Data for the above indicators is included in this pack's data file, which can be used to produce national distribution charts and perform local analysis. CCGs can access further information on the drug groups above via NICE BNF treatment summaries: https://bnf.nice.org.uk/treatment-summary/ Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

https://bnf.nice.org.uk/treatment-summary/

53

Gastrointestinal prescribing: Proton pump inhibitors


54


Proton pump inhibitors (PPIs) are effective short-term treatments for gastric and duodenal ulcers. Following endoscopic treatment of severe peptic ulcer bleeding, an intravenous, high-dose proton pump inhibitor reduces the risk of re-bleeding and the need for surgery. Proton pump inhibitors are widely used for the treatment of dyspepsia and gastro-oesophageal reflux disease.

PPIs are commonly prescribed for the prevention and treatment of NSAID-associated ulcers. In patients who need to continue NSAID treatment after an ulcer has healed, the dose of proton pump inhibitor should normally not be reduced because asymptomatic ulcer deterioration may occur. Indicators on pages 62-66 and 68-69 have been taken from the British National Authority's Medication Safety Dashboard, and highlight whether at-risk patients are being prescribed PPIs and other gastro-protective medicines.

There are also concerns that many people take PPIs for long periods to manage less serious conditions (e.g. indigestion) and may prefer taking them to addressing factors such as diet, obesity or alcohol that may be contributing to their symptoms. NICE have published a case study on how a system successfully reduced PPI usage, due to safety concerns around long-term use and high doses. The key aims of the study was to embed the review of PPIs as part of regular medication reviews, provide healthcare professionals with the means to overcome barriers to reducing PPI use and to raise awareness of PPI usage and management.

https://www.nice.org.uk/sharedlearning/the-way-to-medicines-optimisation-is-through-the-stomach-tackling-high-prescribing-levels-using-the-nice-dyspepsia-guideline-to-review-proton-pump-inhibitor-ppi-prescribing

£36k

55

Primary Care Prescribing: Spend on Proton pump inhibitors per 1,000 STAR-PU

(PPI) weighted population - 2017/18

NHS Blackpool CCG


2,030

1,628 1,828 1,871 1,872 2,015 2,027 2,034 2,065 2,169 2,313

-

500

1,000

1,500

2,000

2,500


Thanet St Helens South Tyneside Knowsley Sunderland Blackpool South Sefton Stoke on Trent South Tees Halton

-

500

1,000

1,500

2,000

2,500

3,000



48k Items

56

Primary Care Prescribing: Proton pump inhibitors - Items per 1,000 STAR-PU

(PPI) weighted population - 2017/18

NHS Blackpool CCG


1,450

1,041 1,208 1,232 1,264 1,265 1,291 1,385 1,399 1,452

1,730

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000


South Sefton St Helens Stoke on Trent Halton South Tyneside South Tees Blackpool Knowsley Sunderland

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000



Identified patient count

Modelled estimated patient count

57

Please note this is only a rough estimate, with the average spend per patient figure assuming that there are no scripts missing for these patients. As such it should be treated with

caution, and combined with local knowledge and analysis. However, it provides useful context for the chart on the next page, which shows the rate of people prescribed a proton

pump inhibitor in 2017/18 based solely on the known ‘Identified patient count’ figure.

This is a count of the number of patients prescribed a drug or appliance within your CCG, using the number of unique NHS Numbers recorded on prescriptions. The chart on the

following page shows the rate of people prescribed a proton pump inhibitor within your CCG, and how this compares nationally and to your similar peers. This can be interpreted as

the number of patients within the 2017/18 financial year who are known to have had at least one prescription of this drug.

Further to the total number of PPI items prescribed, the identified patient count shows the prevalence of PPI prescribing across a population, and enables CCGs to see whether

they are treating more or less patients than their similar peers.

All prescriptions through the Electronic Prescription Service (EPS) will be included in this count, along with a high proportion of the printed paper scripts. However, for a number of

the printed paper scripts the NHS Number will not be attainable due to damage or being incorrect. Nationally, the data completeness of the ‘Identified patient count’ is about 90% for

all prescriptions.

The percentage of spend covered by the Identified patient count for proton pump inhibitor prescriptions in your CCG is 93%.

Due to the data quality issues with the ‘Identified patient count’ figures above, NHS RightCare have estimated the additional number of patients who may have been prescribed a

drug or appliance i.e. the estimated number of patients missed from the ‘Identified patient count’, due to their NHS number not being attained. This has been calculated using the

difference in total spend on a drug or appliance, the spend captured by the identified patient count and the average spend per patient in your CCG (from the population captured in

the identified patient count).

Using the methodology above, it is calculated that an extra 2527 patients were prescribed a proton pump inhibitor in your CCG in 2017/18.

Proton pump inhibitors: Identified patient count data quality summary

34,313 2,527

Number of patients prescribed a protonpump inhibitor

Number of additional patients prescribeda proton pump inhibitor (modelled)

20% 1%

% patients in CCG prescribed a protonpump inhibitor

% patients in CCG prescribed a protonpump inhibitor (modelled)

*

The above indicator shows the rate of unique patients known to have been prescribed a PPI in 2017/18. Please note that CCGs for which less than 90% of their PPI cost can be

attributed to a patient have been excluded due to data quality issues.

58

Primary Care Prescribing: Proton Pump Inhibitors: Identified patient count per

1,000 population - 2017/18

NHS Blackpool CCG

Source: ePACT2 application - NHS Business Services Authority

198 165 171 173 175 176 179 182 183 184 186

-

50

100

150

200

250


Stoke on Trent South Tees Thanet South Tyneside Sunderland South Sefton Knowsley Halton St Helens Blackpool

-

50

100

150

200

250



£5k

The above indicator shows the average spend per unique patient known to have been prescribed a PPI in 2017/18. Opportunity figures show the total reduction in spend that

would occur if a CCG matched the average spend per patient of its lowest 5 similar peers. Opportunities should be considered alongside the overall PPI spend indicator (page 51).

CCGs with a high average spend may want to explore whether they have opportunities to prescribe patients more cost-effective drugs.

59

Primary Care Prescribing: Proton Pump Inhibitors: Mean cost per identified patient

count - 2017/18

NHS Blackpool CCG


11 10 10 10 11 11 11 11 12 12 12

-

2

4

6

8

10

12

14


Knowsley St Helens Blackpool Stoke on Trent Thanet South Tyneside South Sefton Halton Sunderland South Tees

-

2

4

6

8

10

12

14



*

60

Primary Care Prescribing: Percentage of Proton Pump Inhibitors prescribed as

higher dose PPIs (excluding liquids) - 2017/18

NHS Blackpool CCG


90.2

62.1 68.1 68.2 70.282.8 82.9 83.2 85.3 85.8 87.8

-

10

20

30

40

50

60

70

80

90

100

Sunderland St Helens South Tyneside Knowsley Thanet North EastLincolnshire

South Tees South Sefton Halton Stoke on Trent Blackpool

-

10

20

30

40

50

60

70

80

90

100


England Similar 1080.9 77.6

This indicator uses the same definition of 'higher dose' as OpenPrescribing, including standard and double dose PPIs. Although PPIs are safe drugs, their use has been associated with an increase in a number of disorders, including Clostridium difficile infection and a higher risk of community-acquired pneumonia, with an increased risk associated with higher dose PPIs. Because higher dose PPIs will be required to provide effective relief to patients with more severe symptoms, it cannot be said what a CCG's optimum usage should be. For this reason, this indicator has not been RAG rated, no opportunities calculated and a similar 10 benchmark used. OpenPrescribing allows CCGs to analyse monthly changes in their performance for this indicator, and access practice-level breakdowns: https://openprescribing.net/measure/ppidose/

https://openprescribing.net/measure/ppidose/

61

NHS Blackpool CCG

For elderly and other at-risk patients, it is recognised good practice to co-prescribe a PPI with an NSAID. CCGs with high PPI prescribing rates, but low NSAID

prescribing rates, could explore whether opportunities exist to reduce PPI prescribing. CCGs with low PPI prescribing rates, but high NSAID rates, may also want to

explore whether high risk patients are being prescribed gastroprotective medicines. Indicators on the following pages now provide a more detailed view on whether

patients at increased risk of gastrointestinal bleeds are being prescribed PPIs and other gastroprotective medicines.

R² = 0.5463

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

0 100 200 300 400 500 600 700

Item

s fo

r p

roto

n p

um

p in

hib

ito

rs p

er 1

,00

0 S

TAR

-PU

po

pu

lati

on

Primary Care Prescribing: NSAIDs - Items per 1,000 ASTRO-PU weighted population

All CCGs Similar 10 NHS Blackpool CCG

Items for proton pump inhibitors vs. items for NSAIDs - 2017/18

62

Proton pump inhibitors - Medication Safety Dashboard Indicators - 2017/18 Q4How different

are we?

NHS Blackpool CCG

2,986

44

3,302

4,124

2,067

1,063

3,445

42

3,470

3,795

2,199

1,081

10 Patients (NSS)

117 Patients (NSS)

0 1,000 2,000 3,000 4,000 5,000

Taking an NSAID and no gastro-protective

medicine (65+)

Taking an NSAID and an oral anticoagulant

(18+)

Taking an oral anticoagulantwith an anti-platelet and no

gastro-protective medicine (18+)

Taking an aspirin and another anti-platelet and no

gastro-protective medicine (18+)

Taking an NSAID and a SSRI and no gastro-protective

medicine (65+)

Unique patients at increasedrisk of GI bleed (composite

indicator)


patients at increased risk per 10,000 patients at risk

Excluding 'Taking an NSAID and a SSRI and no gastro protective medicine', all of the above indicators have been taken from the BSA's Medication Safety dashboard. The 'Unique patients at increased risk of GI bleed' indicator is a composite measure of the unique patients at increased risk of a GI bleed based on the four other indicators in the dashboard; however patients taking an NSAID and a SSRI and no gastro protective medicine will be included as part of the 'Taking an NSAID and no gastro protective medicine' indicator. For CCGs with higher rates of patients at risk than their best 5 similar peers, 'How different are we?' figures show how many fewer patients would be at increased risk of a GI bleed if they performed to this benchmark. Note that as this is a quarterly indicator, CCG opportunities have been scaled up so to be provided as yearly figures.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

For CCGs with higher rates of patients at risk than their best 5 similar peers, opportunity figures show how many fewer patients would be at increased risk of a GI bleed if they

performed to this benchmark. Note that as this is a quarterly indicator, CCG opportunities have been scaled up so to be provided as yearly figures. This assumes that a different

group of patients are at increased risk each quarter, and CCGs will want to investigate to what extent the cohort included in this indicator has changed or remained the same over

time. Further information for this indicator can be found on the BSA's Medication Safety dashboard interactive atlas:

https://apps.nhsbsa.nhs.uk/MOD/MedicationSafety/atlas.html

63

Primary Care Prescribing: Patients 65 years old or over prescribed a NSAID without a gastro-protective

medicine: Patients at increased risk per 10,000 patients at risk - 2017/18 Q4

NHS Blackpool CCG

Source: ePACT2 application - NHS Business Services Authority - Medication Safety dashboard

2,986 3,229 3,333 3,527 3,534 3,604 3,675 3,789 4,078 4,163 4,421

-

1,000

2,000

3,000

4,000

5,000

6,000

Blackpool South Sefton Stoke on Trent Knowsley North EastLincolnshire

Halton South Tees St Helens Sunderland Thanet South Tyneside

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000



10

Patients






64

Primary Care Prescribing: Patients 18 years old or over prescribed a NSAID and concurrently prescribed

an oral anticoagulant: Patients at increased risk per 10,000 patients at risk - 2017/18 Q4

NHS Blackpool CCG


44

26

45 45 46 48 48 56 60 64 68

-

10

20

30

40

50

60

70

80

90

100

Stoke on Trent Blackpool Sunderland Thanet North EastLincolnshire

South Tyneside South Sefton South Tees Knowsley St Helens Halton

-

20

40

60

80

100

120








65

Primary Care Prescribing: Patients 18 years old or over prescribed an oral anticoagulant with an anti-

platelet and not concurrently prescribed a gastro-protective medicine: Patients at increased risk per

10,000 patients at risk - 2017/18 Q4

NHS Blackpool CCG


3,302 3,111 3,226 3,559 3,721 3,731 3,816 4,231 4,394 4,521 4,722

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Halton South Sefton Blackpool Stoke on Trent Thanet St Helens Sunderland Knowsley North EastLincolnshire

South Tees South Tyneside

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000



117

Patients






66

Primary Care Prescribing: Patients 18 years old or over prescribed aspirin and another anti-platelet and

not concurrently prescribed a gastro-protective medicine: Patients at increased risk per 10,000 patients

at risk - 2017/18 Q4

NHS Blackpool CCG


4,124 3,556 3,667 3,786 3,889 4,077 4,261 4,286 4,583 4,836 5,133

-

1,000

2,000

3,000

4,000

5,000

6,000

Halton Thanet Knowsley St Helens Stoke on Trent Blackpool South Sefton Sunderland South Tyneside South Tees North EastLincolnshire

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000






time.

67

Primary Care Prescribing: Patients over 65 prescribed a NSAID and a SSRI and not concurrently

prescribed a gastro-protective medicine: Patients at increased risk per 10,000 patients at risk - 2017/18

Q4

NHS Blackpool CCG


2,067 2,065 2,102 2,117 2,162 2,549 2,625 2,689 2,774 2,830 2,909

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

Stoke on Trent Blackpool Halton Knowsley South Sefton St Helens Sunderland Thanet South Tees North EastLincolnshire

South Tyneside

-

1,000

2,000

3,000

4,000

5,000

6,000








68

Primary Care Prescribing: Composite metric combining results from individual gastrointestinal bleed

indicators: Patients at increased risk per 10,000 patients at risk - 2017/18 Q4

NHS Blackpool CCG


1,063 952 1,009 1,090 1,144 1,210 1,238 1,259 1,271 1,336 1,383

-

200

400

600

800

1,000

1,200

1,400

1,600

Stoke on Trent South Sefton Blackpool Knowsley Halton South Tees South Tyneside St Helens Sunderland Thanet North EastLincolnshire

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000



For CCGs with higher rates of emergency admissions for GI bleeds than their best 5 similar peers, opportunity figures show how many fewer patients would be admitted if they





69

Primary Care Prescribing: Composite metric combining results from individual gastrointestinal bleed

indicators : Number of admissions per 10,000 patients at risk - 2017/18 Q4

NHS Blackpool CCG


46 40 40 41 52 53

67

-

20

40

60

80

100

120

140

Knowsley South Sefton St Helens North EastLincolnshire

Stoke on Trent South Tees Sunderland Blackpool Thanet South Tyneside Halton

-

20

40

60

80

100

120

140


No Data No Data No Data No Data


52 Adms £90k

Source: National Commissioning Data Repository (NCDR) – Hospital Admissions Databases, SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart) 70NHS Blackpool CCG

CCGs with high rates of emergency spend and admissions for GI bleeds, may wish to consider this in relation to their NSAID prescribing and whether at-risk patients are receiving

gastro-protective medicines such as PPIs. Note that this indicator defines GI bleeds via the ICD-10 codes K920: Haematemesis, K921: Melaena and K922: Gastrointestinal

haemorrhage, unspecified. This is a narrower definition than is used for Medication Safety Dashboard indicators, which also includes bleeding from peptic ulcers and

oesophageal bleeding.

Gastrointestinal bleeds - Non-elective spend per 1,000 age-sex weighted population -

2017/18

1,630

1,042 1,091 1,203 1,209 1,284 1,291 1,406 1,518 1,521 1,818

-

500

1,000

1,500

2,000

2,500

South Sefton St Helens South Tees Stoke on Trent Halton Knowsley North East Lincolnshire Sunderland South Tyneside Blackpool Thanet

-

500

1,000

1,500

2,000

2,500


England 1,168 Best or Lowest 5 1,166

71

Gastrointestinal prescribing: Laxatives






72

Laxatives

Opioid analgesics are widely prescribed drugs used to provide relief for moderate to severe pain. A common side effect of opioids, especially if taken over a long period of time, is constipation. Because of this, recognised good practice is to co-prescribe laxatives as constipation can lead to serious complications.

CCGs with high prescribing rates for opioid analgesics, are therefore more likely to have higher prescribing rates for laxatives. As shown by the chart on the following page, there is a strong correlation between CCG rates of spend on opioids and laxatives. Note that whilst NICE guidance states that bulk-forming laxatives should be avoided for treating opioid-induced constipation, both stimulant laxatives and ostomatic laxatives (shown on pages 51-52) are recommended for the condition.

NICE guidance also states that Naloxegol should be used to treat opioid-induced constipation when response to other laxatives is inadequate. Naloxegol is a peripheral opioid-receptor antagonist, which blocks the constipating effects of opioids without altering their central analgesic effects. Although there is insufficient CCG spend/activity on peripheral opioid-receptor antagonists to show meaningful variation, CCGs with high rates of spend on opioids may want to review their current prescribing practices for these drugs, which are being made increasingly available nationally.

All CCGs should consider their rates of spend on laxatives in light of opioid prescribing, both in terms of whether patients being prescribed opioids are also being effectively treated for constipation, and if through alternative treatments for chronic pain, they could reduce demand for laxatives. CCGs should also consider, where appropriate, encouraging patients to buy over the counter laxatives to reduce prescribing spend in this area.

BMJ have produced an infographic that explores the factors of constipation and choices of laxatives.


https://www.bmj.com/content/bmj/suppl/2017/08/02/bmj.j3313.DC1/bolj035103.wi.pdf

73

NHS Blackpool CCG

As shown by the chart above, a positive correlation exists between CCG rates of items prescribed for laxatives and opioids. The indicator on the following page

shows the percentage of patients prescribed an opioid in your CCG who were co-prescribed a laxative in 2017/18 Q4.

R² = 0.4695

0

100

200

300

400

500

600

700

800

0 200 400 600 800 1,000 1,200

Pri

mar

y C

are

Pre

scri

bin

g: L

axat

ive

s -

Ite

ms

pe

r 1

,00

0 A

STR

O-P

U w

eig

hte

d

po

pu

lati

on

Primary Care Prescribing: Opioid analgesics - Items per 1,000 ASTRO-PU weighted population

All CCGs Similar 10 NHS Blackpool CCG

Items for laxatives vs. items for opioid analgesics – 2017/18

1,082

Patients

Patients who are prescribed an opioid may be prescribed a large amount of laxative upfront which will last for a longer period than their opioid prescription. For this reason, this

indicator defines 'concurrently' as any patient who was prescribed an opioid for all three months of 2017/18 Q4, and a laxative in any ones of these months. Please note this is a

different definition to the one used by the Medication Safety dashboard, which requires a laxative to be prescribed in all three months. It may also be that patients who aren't

being prescribed laxatives are instead purchasing them whilst taking an opiate.

For CCGs where a lower percentage of patients are co-prescribed a laxative than their highest 5 peers, opportunity figures show how many more patients would be co-prescribed

a laxative if they performed to this benchmark. Note that as this is a quarterly indicator, CCG opportunities have been scaled up so to be provided as yearly figures. This assumes

that a different group of patients are not co-prescribed a laxative each quarter, and CCGs will want to investigate to what extent the cohort included in this indicator has changed

or remained the same over time. CCGs where a low percentage of people are co-prescribed a laxative with an opioid will also want to investigate this further, and whether opioid

patients who aren't co-prescribed laxatives are being admitted to secondary care due to problems caused by constipation.

74

Primary Care Prescribing: Percentage of patients prescribed an opioid who are

concurrently prescribed a laxative - 2017/18 Q4

NHS Blackpool CCG


18 18 18 19 19 20 20 21 22 22 24

-

5

10

15

20

25

30


Blackpool South Tees Sunderland Halton South Tyneside Stoke on Trent Knowsley St Helens South Sefton

-

5

10

15

20

25

30

35


England Highest 521 22

CCG spend on laxatives should be considered alongside their opioid prescribing rates. CCGs with low spend on laxatives but high opioid usage, will want to consider whether more

patients should be prescribed laxatives.

75

Primary Care Prescribing: Spend on Laxatives per 1,000 ASTRO-PU weighted


NHS Blackpool CCG


1,556 1,248

1,765 1,792 1,850 1,918 2,130 2,205 2,365 2,404

2,648

-

500

1,000

1,500

2,000

2,500

3,000


Blackpool Halton Thanet St Helens Stoke on Trent Knowsley South Tees Sunderland South Sefton South Tyneside

-

500

1,000

1,500

2,000

2,500

3,000



5k Items

CCG items for laxatives should be considered alongside their opioid prescribing rates. CCGs with low items prescribed for laxatives but high opioid usage, will want to consider

whether more patients should be prescribed laxatives.

76

Primary Care Prescribing: Laxatives - Items per 1,000 ASTRO-PU weighted


NHS Blackpool CCG


358 277 277

338 373 384 419 422 443

600 651

-

100

200

300

400

500

600

700


Halton Blackpool Stoke on Trent St Helens South Sefton Knowsley South Tees South Tyneside Sunderland

-

100

200

300

400

500

600

700

800



*

77

Primary Care Prescribing: Macrogols and lactulose: Percentage of items

prescribed which are macrogols - 2017/18

NHS Blackpool CCG


60.352.5 55.7 56.5 57.0 57.0 61.8 67.6 70.2

82.1 82.3

-

10

20

30

40

50

60

70

80

90


St Helens Knowsley Halton South Sefton Blackpool Stoke on Trent Thanet South Tees South Tyneside Sunderland

-

10

20

30

40

50

60

70

80

90



Lactulose can cause bloating and colic when used alone in opioid-induced constipation. CCGs where a low percentage of macarogols are prescribed relative to lactulose, may wish to investigate whether patients could be better managed through macrogols. Note that opportunities are not calculated for this indicator, and the similar 10 benchmark is used instead of best/lowest five. See the NICE Clinical Knowledge Summary on constipation for more information: https://cks.nice.org.uk/constipation#!prescribinginfosub:2

https://cks.nice.org.uk/constipation

67 Adms £72k

Source: National Commissioning Data Repository (NCDR) – Hospital Admissions Databases, SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart) 78

CCGs with high rates of emergency spend and admissions for constipation, may wish to explore whether opportunities were missed to manage these patients in primary care

and if hospital admissions could have been avoided through increased access to laxatives.

NHS Blackpool CCG

Constipation - Non-elective spend per 1,000 age-sex weighted


1,501

761 764

1,337 1,364 1,371 1,381 1,439 1,451 1,518

1,890

-

500

1,000

1,500

2,000

2,500

Thanet North East Lincolnshire Sunderland Stoke on Trent South Tyneside Halton South Sefton Knowsley Blackpool St Helens South Tees

-

500

1,000

1,500

2,000

2,500



79

Gastrointestinal prescribing: Stoma care



80

Stoma prescribing - Overview

The Royal College of Nursing estimates that around 100,000 people in the UK have a stoma. A stoma is a surgical opening on the front of the abdomen which allows faeces or urine to be collected in a pouch outside the body. Stomas can be formed for a number of reasons, such as cancer, diverticular disease or inflammatory bowel disease.

All stoma patients require a stoma appliance to collect faeces (ileostomy and colostomy) or urine (urostomy) and at least one stoma accessory (additional items to help with the management of a stoma) on prescription. Data for all of these is collected under BNF Chapter 23: Stoma appliances. In 2017/18, data from the NHS Business Services Authority shows that total CCG spend across this chapter was £292 million, with over 5.7 million items prescribed.

Indicators on pages 85-88 show CCG expenditure on high-level groupings of stoma items: appliances, accessories, skin fillers and protectives, and stoma items not recommended for routine prescribing. These definitions align with that used by PrescQIPP, of which there is more information available on the following page.

When viewing stoma indicators on the following pages, it is important to note that much of the spend and activity will be driven by treatment for colorectal cancer, as well as non-cancerous gastrointestinal conditions. Urostomy appliances and accessories are also included in the indicators, which are prescribed following treatment for early bladder cancer and non-cancerous genitourinary conditions. Although primarily used to treat stomas, items within BNF Chapter 23 such as colostomy and ileostomy bags are also prescribed as wound care products.

It should also be noted that different models of providing stoma products other than GP FP10 prescribing are starting to be used by some CCGs. Stoma products not provided through FP10 are excluded from the following indicators, meaning data may not be directly comparable between similar CCGs.

https://www.rcn.org.uk/professional-development/publications/pub-003520

81

CCGs can access more detailed data about their stoma prescribing via PrescQIPP, a NHS funded not-for-profit organisation that supports quality, optimised prescribing for patients.

Further to online data and analysis, PrescQIPP have published a bulletin that provides advice on appropriate stoma prescribing and includes several recommendations. These include:

• Ensure that stoma products are being prescribed in accordance with local appliance and formulary guidance and recommendations to minimise wastage.

• Ensure appropriate quantities of products are prescribed to minimise wastage.

• Ensure regular review of prescribing for all patients with a stoma and assess appliance and accessory use in line with patient needs and prescribing recommendations. Where there is no need for products, discontinue prescribing and remove from repeat.

Other freely available resources include bulletins on barrier products and adhesive removers.

The NHS London Procurement Partnership are also undertaking a project to improve the prescribing of stoma products across London. Its aims are to identify factors that lead to over-prescribing in order to reduce waste, introduce best practice stoma care guidelines, design a formulary detailing high quality, cost effective products with recommended prescribing guidance and, make efficiency savings without compromising patient care.

For more information about the project, please contact:

• Wajid Qureshi, Stoma Care Project Lead, [email protected]

• Zarah Perry-Woodford, Consultant Nurse, Stoma Care, [email protected]

Stoma prescribing – Further resources

https://www.prescqipp.info/our-resources/bulletins/bulletin-105-stoma/

https://www.prescqipp.info/our-resources/bulletins/bulletin-181-barrier-products/

https://www.prescqipp.info/our-resources/bulletins/bulletin-189-continence-and-stoma-adhesive-removers/

http://www.lpp.nhs.uk/



82

Stoma prescribing summary - Spend - 2017/18How different

are we?

NHS Blackpool CCG

6,375

4,829

616

891

39

5,875

4,238

567

862

64

£94k

£111k

£9k

£5k

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000


Appliances

Skin fillers and protectives

Accessories

Items not recommended forroutine prescribing


per 1,000 ASTRO-PU weighted population

Different models of providing stoma products other than GP FP10 prescribing are starting to be used by some CCGs. Stoma products not provided through FP10 are excluded from the above indicators, meaning data may not be directly comparable between similar CCGs and opportunity figures not realistic.Items not recommended for routine prescribing include deodorants, irrigation washout appliances, bag covers, filters/bridges and bag closures. The definition for this and all other stoma prescribing indicators aligns with those used by PrescQIPP.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

Note - opportunities won’t be shown when less than 500 items. 83

Stoma prescribing summary - Items - 2017/18How different

are we?

NHS Blackpool CCG

109

29

55

22

2

115

28

53

27

4

0 20 40 60 80 100 120


Appliances

Skin fillers and protectives

Accessories

Items not recommended for routine prescribing


per 1,000 ASTRO-PU weighted population

Different models of providing stoma products other than GP FP10 prescribing are starting to be used by some CCGs. Stoma products not provided through FP10 are excluded from the above indicators, meaning data may not be directly comparable between similar CCGs and opportunity figures not realistic.Items not recommended for routine prescribing include deodorants, irrigation washout appliances, bag covers, filters/bridges and bag closures. The definition for this and all other stoma prescribing indicators aligns with those used by PrescQIPP.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

£94k

Different models of providing stoma products other than GP FP10 prescribing are starting to be used by some CCGs. Stoma products not provided through FP10 are excluded from

the above indicator, meaning data may not be directly comparable between similar CCGs and opportunity figures not realistic.

84

Primary Care Prescribing: Spend on Stoma per 1,000 ASTRO-PU weighted


NHS Blackpool CCG


6,375 5,254 5,798 5,855 6,229 6,236 6,440 6,604 6,609

7,303 7,670

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Stoke on Trent St Helens South Tyneside South Sefton Knowsley Blackpool North EastLincolnshire

Sunderland South Tees Halton Thanet

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000



£111k



85

Primary Care Prescribing: Spend on Stoma appliances per 1,000 ASTRO-PU

weighted population - 2017/18

NHS Blackpool CCG


4,829

3,661 4,089 4,325 4,515 4,601 4,686 4,723 5,059 5,197 5,238

-

1,000

2,000

3,000

4,000

5,000

6,000

Stoke on Trent South Tyneside St Helens South Sefton North EastLincolnshire

Sunderland Knowsley Blackpool South Tees Halton Thanet

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000



£9k



86

Primary Care Prescribing: Spend on Skin fillers and protectives per 1,000 ASTRO-

PU weighted population - 2017/18

NHS Blackpool CCG


616 502 534 552 600 647 725 805

946 1,039

1,166

-

200

400

600

800

1,000

1,200

1,400

Knowsley South Tees Stoke on Trent St Helens Blackpool Sunderland South Sefton South Tyneside North EastLincolnshire

Halton Thanet

-

200

400

600

800

1,000

1,200

1,400



£5k



87

Primary Care Prescribing: Spend on Stoma accessories per 1,000 ASTRO-PU


NHS Blackpool CCG


891 816 834 866 877 917 957 970 989 1,181 1,184

-

200

400

600

800

1,000

1,200

1,400


St Helens South Tyneside South Sefton Blackpool South Tees Knowsley Stoke on Trent Halton Thanet Sunderland

-

200

400

600

800

1,000

1,200

1,400

1,600





88

Primary Care Prescribing: Spend on Stoma items not recommended for routine

prescribing per 1,000 ASTRO-PU weighted population - 2017/18

NHS Blackpool CCG


39 39 54

71 78 78 85 87 95 98 111

-

20

40

60

80

100

120

140

Blackpool St Helens Knowsley Stoke on Trent North EastLincolnshire

Halton Thanet Sunderland South Tyneside South Tees South Sefton

-

20

40

60

80

100

120

140



89

Section five: Referral to treatment waiting times

90

Consultant-led referral to treatment (RTT) waiting times

Consultant-led RTT waiting times is a monthly NHS collection. It records how long patients are waiting to start non-emergency consultant-led treatment. Data is provided for incomplete pathways (waiting times for patients waiting to start treatment at the end of each month), completed admitted pathways (waiting times for patients whose treatment started during the month) and completed non-admitted pathways (waiting times for patients whose wait for treatment ended during the month for reasons other than an inpatient or day case admission).

The incomplete waiting time standard was introduced in 2012. This states that the time waited must be 18 weeks or less for at least 92% of patients on incomplete pathways. There is no operational waiting times standard for completed pathways.

The chart on the following page highlights monthly changes in your CCG performance for patients waiting to start treatment by consultants specialising in gastroenterology, with the 92% standard highlighted. It is advised that CCGs who are consistently falling below the standard review the reasons for this, and understand the factors which might be causing patients to be waiting more than 18 weeks.

More information about RTT waiting times can be found on the collection's web page:https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/

https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/

NHS Blackpool CCG

91

Referral to treatment waiting times: % of gastroenterology patients waiting

under 18 weeks for incomplete pathways - 2017/18

60

65

70

75

80

85

90

95

100

April May June July August September October November December January February March

Pa

tien

ts s

een

with

in 1

8 w

eeks (

%)

Month

The chart above highlights monthly changes in your CCG performance for patients waiting to start treatment by consultants specialising in Gastroenterology, with the 92% standard highlighted. It is advised that CCGs who are consistently falling below the standard review reasons for this, and understand factors which might be causing patients to waiting more than 18 weeks. More information about RTT waiting times can be found at https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/ .

If there isn't a CCG value for every month in the graph above, the CCG's values will have been suppressed. A CCG’s data is suppressed if trusts who accounted for 50% or more of the CCG’s secondary care activity did not submit data for a particular month.


92

Section six: Outpatient spend and attendances

93

Gastrointstinal outpatient summary

The following section focusses on CCG GI outpatient expenditure and activity.

It includes an overall spend indicator for all GI outpatient attendances and procedures. This has been produced using data from the programme budgeting collection. Outpatient attendances have been mapped to the GI programme budgeting category using treatment function codes (TFC). Outpatient procedures have been mapped using healthcare resource groups (HRGs). For more information on the programme budgeting expenditure dataset, please see pages 295-297.

Also included are SUS+ CCG outpatient activity for the activity for the outpatient TFC of most relevance to the GI programme budgeting category. Only those TFCs classed as ‘specific acute’ have been included, and only where there is sufficient activity nationally. The TFCs included are listed below:

• Gastroenterology and paediatric gastroenterology (TFC Codes 301 and 251)

• Hepatology (TFC code 306)

• Upper gastrointestinal surgery (TFC code 106)

• Oral surgery (TFC code 140)

Indirectly age-sex standardised rates of attended outpatient appointments for each TFC are shown – this includes both attended new (first) and follow-up appointments. Potential opportunities are provided by comparing each CCG’s rate to the average activity rates of its lowest 5 similar CCGs; as for primary care prescribing and elective inpatient admissions, local interpretation is required to determine whether higher or lower rates of outpatient appointments for the TFC are appropriate.

There is likely to be significant variation nationally in how attended appointments are allocated to TFCs, particularly to the general Surgery and general Medicine TFCs. These TFCs are included in the NHS RightCare Where to Look pack as they do not align with a specific programme.

94

GI outpatient summary (cont.)

Also included in this section are indicators measuring of all new and follow-up outpatient attendances, the percentage that are new. This indicator is provided to provide further context to the overall rate of appointments indicator, and for CCGs to see on average how many follow-up appointments a patient has. Variation in this measure is likely due to two key factors; the mix of patients and the treatment method chosen, and provider processes. However, given the amount of variation nationally, it is likely that provider processes are the key driver.

CCGs with higher percentages of new appointments (and therefore on average their patients are having fewer follow-up appointments) may find that their patients are having a poorer experience of care and may be more likely to be re-referred. It may also be an indication of over-referral from primary care, or prioritisation of new patient appointments in the outpatient setting.

CCGs with lower percentages of new appointments (and therefore on average their patients are having more follow-up appointments) may find that their capacity for seeing new patients is limited and may want to analyse their referral to treatment and waiting times data. It may also indicate under-referral from primary care.

NHS RightCare encourages systems to use outpatient data to identify potential opportunities to reduce burden of referrals to secondary care services where appropriate. Working with trusts and primary care, systems should work collectively to understand the drivers for their outpatient appointment rates in specific clinical specialties, and to ensure that local referral processes are appropriate and being adhered to. The NHS Operational Planning and Contracting guidance for 2019/20 states that systems should increase the focus on the development of primary care service to further reduce referrals and follow-ups.

Please note that SUS outpatient spend and activity data on specific GI procedures, is included in the endoscopy (pages 177-208) and haemorrhoid and other lower gastrointestinal procedures (pages 267-272) pack sections.

*





95

Gastrointestinal problems (PBC 13) - Outpatient attendances and procedures

spend per 1,000 overall weighted population (PB dataset) - 2017/18

NHS Blackpool CCG


6,136 5,925 6,647 7,528 8,122 8,125 8,168 8,408 8,962 9,059

10,974

-

2,000

4,000

6,000

8,000

10,000

12,000

Stoke on Trent Blackpool Sunderland North EastLincolnshire

South Tyneside South Tees St Helens Halton Thanet Knowsley South Sefton

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000


England Similar 107,563 8,192

Only attended appointments are included in these indicators. They include both new (first) and follow-up appointments.

Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further

analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

96

GI outpatient summary - Rate of appointments - 2017/18How different

are we?

NHS Blackpool CCG

3,417

87

78

2,707

3,900

55

288

1,183

59 Appointments

2729 Appointments

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000

Gastroenterology (including paediatrics)

Hepatology

Upper GI Surgery

Oral surgery


per 100,000 age-sex weighted population

97

GI outpatient summary - Percentage of appointments which are new - 2017/18

NHS Blackpool CCG

32

18

36

38

32

16

36

45

0 10 20 30 40 50

Gastroenterology (including paediatrics)

Hepatology

Upper GI Surgery

Oral surgery

Blackpool Similar 10

Percent (%)

CCGs with higher percentages of new appointments (and therefore on average their patients are having fewer follow-up appointments) may find that their patients are having a poorer experience of care and may be more likely to be re-referred. It may also be an indication of over-referral from primary care, or prioritisation of new patient appointments in the outpatient setting.CCGs with lower percentages of new appointments (and therefore on average their patients are having more follow-up appointments) may find that their capacity for seeing new patients is limited and may want to analyse their referral to treatment and waiting times data. It may also indicate under-referral from primary care. As it cannot be said what represents an optimum performance for these indicators, a similar 10 benchmark is used and no opportunities are calculated.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

Only attended appointments are included in this indicator. This indicator includes both new (first) and follow-up appointments.

98

Gastroenterology - Rate of outpatient appointments per 100,000 age-sex weighted


NHS Blackpool CCG


3,417 3,135 3,198 3,643 4,533

4,992 5,476 5,487

6,022 6,070 6,227

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000


Stoke on Trent Blackpool Thanet Halton South Tyneside South Tees St Helens South Sefton Sunderland Knowsley

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000



59 Appts


99

Hepatology - Rate of outpatient appointments per 100,000 age-sex weighted


NHS Blackpool CCG


87 36 48 51 67 74

119 128 168 191

345

-

50

100

150

200

250

300

350

400

South Sefton Knowsley North EastLincolnshire

South Tees St Helens Blackpool Stoke on Trent Halton Sunderland Thanet South Tyneside

-

500

1,000

1,500

2,000

2,500




100

Upper gastrointestinal surgery - Rate of outpatient appointments per 100,000 age-

sex weighted population - 2017/18

NHS Blackpool CCG


78 76 134 339 418 471 560

654 685 795

1,222

-

200

400

600

800

1,000

1,200

1,400

Thanet Blackpool St Helens Knowsley Halton South Tees South Sefton South Tyneside Stoke on Trent Sunderland North EastLincolnshire

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800



2,729

Appts


101

Oral surgery - Rate of outpatient appointments per 100,000 age-sex weighted


NHS Blackpool CCG


2,707

708 801 1,140

1,391 1,873 1,993

2,285 2,821 2,976 2,981

-

500

1,000

1,500

2,000

2,500

3,000

3,500

Stoke on Trent Halton South Tees North EastLincolnshire

Knowsley South Sefton St Helens Blackpool South Tyneside Sunderland Thanet

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500



*

CCGs with a higher percentage of new appointments may find that patients are having a poorer experience of care and are more likely to be re-referred. It may also indicate over-

referral from primary care, or prioritisation of new outpatient appointments over follow-ups. CCGs with a lower percentage may find that their capacity for seeing new patients is

limited and should check their RTT data. It may also indicate under-referral from primary care. As it cannot be said what represents an optimum performance for this indicator, a

similar 10 benchmark is used and no opportunities are calculated.

102

Gastroenterology - Percentage of outpatient appointments which are new -

2017/18

NHS Blackpool CCG


32.0

23.5 25.230.7 31.0 31.4 31.9 34.0 34.5 35.4

41.8

-

5

10

15

20

25

30

35

40

45

South Tyneside North EastLincolnshire

Thanet Knowsley Halton St Helens Blackpool Sunderland South Sefton Stoke on Trent South Tees

-

10

20

30

40

50

60

70



*





103

Hepatology - Percentage of outpatient appointments which are new - 2017/18

NHS Blackpool CCG


17.6

8.011.4

14.316.9 18.0 18.0 19.1 19.6

22.1

-

5

10

15

20

25

30

South Sefton Stoke on Trent Knowsley South Tyneside North EastLincolnshire

Blackpool Thanet Halton St Helens South Tees Sunderland

-

10

20

30

40

50

60

70


No Data


*





104

Upper gastrointestinal surgery - Percentage of outpatient appointments which are

new - 2017/18

NHS Blackpool CCG


35.9

24.8 28.2 29.9 31.338.2 38.2 38.4 39.2 39.7

53.8

-

10

20

30

40

50

60

Thanet St Helens Sunderland South Tyneside Blackpool North EastLincolnshire

South Sefton Knowsley South Tees Halton Stoke on Trent

-

10

20

30

40

50

60

70

80



*





105

Oral surgery - Percentage of outpatient appointments which are new - 2017/18

NHS Blackpool CCG


38.331.7 34.5 35.6 38.3 40.1 40.5 40.7 44.3 47.5

94.2

-

10

20

30

40

50

60

70

80

90

100

Halton Sunderland South Sefton Blackpool Knowsley St Helens South Tyneside Thanet South Tees North EastLincolnshire

Stoke on Trent

-

10

20

30

40

50

60

70

80

90

100



106

Section seven: Programme and condition level inpatient spend

107

Condition level inpatient spend: Programme budgeting categories

Charts in the following section will highlight variation in total, elective and non-elective expenditure across the whole gastrointestinal programme budgeting category (13). For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

The GI programme budgeting category is broken down into four sub-categories: upper GI problems (13A), lower GI problems (13B), hepatobiliary problems (13C) and other GI problems (13X). The table below shows how elective and non-elective spend is split across these categories nationally.

In the sections that follow, charts will highlight variation in each of these sub-categories, as well as theconditions which drive expenditure in these areas.



Gastrointestinal problems (PBC 13) - Spend per 1,000 age-sex weighted

population (SUS+ data) - 2017/18

47,435 44,349 49,263 50,625 51,233 52,410 54,625 57,367 58,615 59,588

63,703

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

Thanet Blackpool Stoke on Trent Sunderland North EastLincolnshire

South Tyneside South Tees St Helens Halton South Sefton Knowsley

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000



*





109

Gastrointestinal problems (PBC 13) - Total inpatient spend per 1,000 overall

weighted population (PB dataset) - 2017/18

NHS Blackpool CCG


37,644 43,053 45,758 46,376 46,668 47,269 49,255 50,658 51,905 52,828 54,596

-

10,000

20,000

30,000

40,000

50,000

60,000

Blackpool Stoke on Trent Sunderland South Tyneside South Tees North EastLincolnshire

Thanet Halton South Sefton St Helens Knowsley

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000




Elective inpatient spend indicators should be considered alongside spend on outpatient attendances and procedures (page 95).

NHS Blackpool CCG

Gastrointestinal problems (PBC 13) - Elective spend per 1,000 age-sex

weighted population (SUS+ data) - 2017/18

17,529 17,327 20,206

22,127 22,356 23,034 24,354 24,365 25,220 25,575 26,374

-

5,000

10,000

15,000

20,000

25,000

30,000

Stoke on Trent Blackpool Thanet South Tees South Tyneside Sunderland North East Lincolnshire St Helens South Sefton Halton Knowsley

-

5,000

10,000

15,000

20,000

25,000

30,000



*




refer to pages 295 to 298. Elective inpatient spend indicators should be considered alongside spend on outpatient attendances and procedures (page 95).

111

Gastrointestinal problems (PBC 13) - Elective spend per 1,000 overall weighted

population (PB dataset) - 2017/18

NHS Blackpool CCG


14,465 15,640 18,494 19,417 19,594 20,847 21,176 21,313 22,651 22,937 23,599

-

5,000

10,000

15,000

20,000

25,000

Blackpool Stoke on Trent South Tees South Tyneside South Sefton Sunderland St Helens Thanet Knowsley Halton North EastLincolnshire

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000



157 Adms £326k


Gastrointestinal problems (PBC 13) - Non-elective spend per 1,000 age-

sex weighted population (SUS+ data) - 2017/18

29,877 24,191

26,902 27,577 30,054 31,954 32,501 33,004 33,015 34,368

37,350

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

Thanet North East Lincolnshire Sunderland Blackpool South Tyneside Stoke on Trent South Tees St Helens Halton South Sefton Knowsley

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000



*





113

Gastrointestinal problems (PBC 13) - Non-elective spend per 1,000 overall


NHS Blackpool CCG


23,179 23,670 24,911 26,959 27,414 27,721 27,943 28,173 31,652 31,945 32,311

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Blackpool North EastLincolnshire

Sunderland South Tyneside Stoke on Trent Halton Thanet South Tees St Helens Knowsley South Sefton

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000



114

Upper gastrointestinal problems - Elective spend

115

Upper GI problems (13A): Elective spend

Charts in the following section will highlight variation in CCG elective spend for upper GI problems (13A), and conditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell under upper GI problems in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG'sspend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bedday indicators are available in the data file for this pack.

For elective upper GI spend, conditions make up 69% of the programme budget total nationally.




NHS Blackpool CCG

Upper GI problems (PBC 13A) - Elective spend per 1,000 age-sex


3,811 4,354 4,522

5,751 5,802 5,876 6,060 6,417 6,491 6,683 6,755

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Blackpool Thanet Stoke on Trent South Sefton South Tees Sunderland Halton St Helens South Tyneside North East Lincolnshire Knowsley

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000



*





117

Upper GI problems (PBC 13A) - Elective spend per 1,000 overall weighted


NHS Blackpool CCG


2,987 3,748

4,370 4,398 4,772 4,803 5,172 5,331 5,611 5,718 6,277

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Blackpool Stoke on Trent South Sefton South Tees Sunderland Thanet South Tyneside Halton St Helens Knowsley North EastLincolnshire

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000



Condition Group

118

Upper GI - Spend on elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

545

305

415

224

591

464

782

459

1,027

378

236

205

£64k

£49k

0 100 200 300 400 500 600 700

Gastro-oesophageal refluxdisease and oesophagitis

Barrett's oesophagus

Gastritis and duodenitis

Other diseases of stomach and duodenum

Gastrointestinal bleeds

Aphagia and dysphagia (inability and difficulty

swallowing)



The majority of CCG spend and activity for all the above indicators is driven by day case diagnostic endoscopies performed in an inpatient setting. The endoscopy section of the pack (pages 177-208) provides a more detailed view of CCG diagnostic endoscopic activity. Elective admissions for upper GI conditions should be considered as part of the upper GI pathway on a page (page 23).Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

119

Lower gastrointestinal problems - Elective spend

120

Lower GI problems (13B): Elective spend


Charts in the following section will highlight variation in CCG elective spend for lower GI problems (13B), and conditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell under lower GI problems in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG's spend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bed day indicators are available in the data file for this pack.

For elective lower GI spend, conditions make up 96% of the programme budget total nationally.



NHS Blackpool CCG

Lower GI problems (PBC 13B) - Elective spend per 1,000 age-sex


5,036 5,176 5,516 5,576 6,315 6,376 6,733 6,980 7,331

8,018 8,279

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Blackpool Stoke on Trent South Tyneside South Tees Thanet Sunderland Halton St Helens North East Lincolnshire South Sefton Knowsley

-

2,000

4,000

6,000

8,000

10,000



*





122

Lower GI problems (PBC 13B) - Elective spend per 1,000 overall weighted


NHS Blackpool CCG


4,148 4,651 4,674 4,679 5,744 5,926 5,953 6,095 6,281

6,835 6,932

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Blackpool Stoke on Trent South Tyneside South Tees Sunderland South Sefton St Helens Halton Thanet North EastLincolnshire

Knowsley

-

2,000

4,000

6,000

8,000

10,000

12,000



Condition Group

123

Lower GI - Spend on elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

Excluding fissure and fistula of anal and rectal regions, and encounter for attention to gastrostomy, colostomy or ileostomy, the majority of CCG spend and activity for the above indicators is driven by day case diagnostic endoscopies performed in an inpatient setting. The endoscopy section of the pack (pages 177-208) provides a more detailed view of CCG diagnostic endoscopic activity. Further information and data on Crohn's disease and ulcerative colitis can be found in the IBD section of the pack (pages 158-174). Further information and data on haemorrhoids and perianal venous thrombosis can be found in the haemorrhoid section (pages 267-272).Also note that detecting and removing colonic polyps reduces the likelihood of a patient developing bowel cancer. High spend rates on 'polyp of colon' may therefore represent good practice, and lower spend rates indicate that opportunities are being missed at detect and treat at-risk patients.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

669

332

491

642

156

236

766

865

296

459

729

653

488

177

907

258

243

652

695

241

277

748

£3k (NSS)

£57k

£22k

£33k

£10k

£34k

0 200 400 600 800 1,000

Crohn's disease

Ulcerative colitis

Other, unspecified noninfectivegastroenteritis and colitis

Diverticular disease of intestine without perforation or abscess

Constipation

Fissure and fistula of analand rectal regions

Other diseases of anusand rectum

Polyp of colon

Change in bowel habit

Encounter for attention: gastrostomy,colostomy and ileostomy

Haemorrhoids and perianal venous thrombosis



124

Hepatobiliary problems - Elective spend

125

Hepatobiliary problems (13C): Elective spend


Charts in the following section will highlight variation in CCG elective spend for hepatobiliary problems (13C), and conditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell under hepatobiliary problems in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG's spend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bed day indicators are available in the data file for this pack.

For elective hepatobiliary spend, conditions make up 93% of the programme budget total nationally.



NHS Blackpool CCG

Hepatobiliary problems (PBC 13C) - Elective spend per 1,000 age-sex


3,373 2,575

3,327 3,413 3,978 4,212 4,247 4,535 4,563 4,837 4,851

-

1,000

2,000

3,000

4,000

5,000

6,000

Stoke on Trent South Sefton Blackpool Thanet South Tees St Helens North East Lincolnshire Sunderland Knowsley Halton South Tyneside

-

1,000

2,000

3,000

4,000

5,000

6,000



*





127

Hepatobiliary problems (PBC 13C) - Elective spend per 1,000 overall weighted


NHS Blackpool CCG


2,705 2,283

2,845 3,402

3,765 3,856 4,083 4,214 4,429 4,441 4,472

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

Stoke on Trent Blackpool South Sefton South Tees St Helens Thanet Knowsley North EastLincolnshire

Halton South Tyneside Sunderland

-

1,000

2,000

3,000

4,000

5,000

6,000



Condition Group

128

Hepatobiliary - Spend on elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

766

2,062

270

505

2,242

293

£50k

0 500 1,000 1,500 2,000 2,500

Liver disease

Gallbladder disease

Bile duct stones



The majority of CCG elective inpatient spend for gallbladder disease is driven by procedures to remove the gallbladder (cholecystectomy). The cholecystectomy section of the pack (starting on page 209) provides a more detailed view of CCG performance in this area. The majority of CCG elective inpatient spend for bile duct stones is driven by ERCP procedures, further information on which can be found on page 225. Elective management of gallstones and ductal stones may reduce the admissions/readmission with biliary sepsis, so 'how different are we' figures for gallbladder disease and bile duct stones require careful interpretation. Further information and data on liver disease can be found in the pathway on a page (pages 14-17), and the oesophageal varices, paracentesis and liver transplant section (pages 248-258). Note that liver disease condition indicators align with PHE's definition of liver disease, which includes admissions and deaths due to liver cancer.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

129

Other gastrointestinal problems - Elective spend

130

Other problems of GI (13X): Elective spend


Charts in the following section will highlight variation in CCG elective spend for other problems of GI (13X), and conditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset Section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell under other problems of GI in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG's spend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bed day indicators are available in the data file for this pack.

For elective other GI spend, conditions make up 83% of the programme budget total nationally.



NHS Blackpool CCG

Other GI problems (PBC 13X) - Elective spend per 1,000 age-sex


5,307 5,049 5,499 6,102 6,131 6,248

6,755 6,762 6,774 7,939 8,126

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Stoke on Trent Blackpool South Tyneside North East Lincolnshire Thanet Sunderland St Helens South Tees Knowsley Halton South Sefton

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000



*





132

Other GI problems (PBC 13X) - Elective spend per 1,000 overall weighted


NHS Blackpool CCG


4,625 4,958 5,131 5,847 5,860 5,918 6,015 6,273 6,374 6,452

7,083

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Blackpool Stoke on Trent South Tyneside St Helens Sunderland Knowsley South Tees North EastLincolnshire

Thanet South Sefton Halton

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000



Condition Group

133

Other GI - Spend on elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

The hernia section of the pack (pages 226-238) provides further information and data on hernia repair procedures. Elective inpatient spend on inguinal hernia should also be

considered alongside the groin hernia pathway on a page (page 20).

Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis

to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

206

1,425

527

802

397

233

1,537

372

718

553

£28k

£16k (NSS)

0 200 400 600 800 1,000 1,200 1,400 1,600 1,800

Infectious gastroenteritis and colitis, unspecified

Inguinal hernia

Umbilical hernia

Ventral hernia

Diaphragmatic hernia



134

Upper gastrointestinal problems - Non-elective spend

135

Upper GI problems (13A): Non-elective spend


Charts in the following section will highlight variation in CCG non-elective spend for upper GI problems (13A), andconditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell under upper GI problems in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG's spend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bed day indicators are available in the data file for this pack.

For non-elective upper GI spend, conditions make up 75% of the programme budget total nationally.

113 Adms £214k


Upper GI problems (PBC 13A) - Non-elective spend per 1,000 age-sex


7,288

4,789 5,578 6,120

7,045 7,247 7,282 7,639 8,251 9,108

10,318

-

2,000

4,000

6,000

8,000

10,000

12,000

Sunderland North East Lincolnshire Thanet South Tyneside Stoke on Trent South Sefton Blackpool Halton St Helens South Tees Knowsley

-

2,000

4,000

6,000

8,000

10,000

12,000



*





137

Upper GI problems (PBC 13A) - Non-elective spend per 1,000 overall weighted


NHS Blackpool CCG


5,599

4,144 4,664 5,999 6,157 6,321 6,480 6,810

7,501 7,742 7,986

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Sunderland North EastLincolnshire

Blackpool Stoke on Trent Halton South Tyneside South Sefton Thanet South Tees St Helens Knowsley

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000



Condition Group

Non-elective inpatient spend on gastrointestinal bleeds should also be considered alongside the PPI section (starting on page 53). Non-elective admissions for upper GI conditions

should be considered as part of the upper GI pathway on a page (page 23).



138

Upper GI - Spend on non-elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

903

996

1,015

1,630

244

648

866

702

1,166

164

£48k

£25k (NSS)

£58k

£90k

£16k (NSS)

0 500 1,000 1,500 2,000

Gastro-oesophageal refluxdisease and oesophagitis

Peptic ulcers

Gastritis and duodenitis

Gastrointestinal bleeds

Aphagia and dysphagia(inability and difficulty

swallowing)



139

Lower gastrointestinal problems - Non-elective spend

140

Lower GI problems (13B): Non-elective spend


Charts in the following section will highlight variation in CCG non-elective spend for lower GI problems (13B), and conditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus(SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programmebudgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell underlower GI problems in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG's spend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bed day indicators are available in the data file for this pack.

For non-elective lower GI spend, conditions make up 92% of the programme budget total nationally.

73 Adms £143k


Lower GI problems (PBC 13B) - Non-elective spend per 1,000 age-sex


7,037

5,760 6,035 6,178 6,483 6,746 7,144 7,368 7,582 7,626 7,629

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Thanet South Tyneside Sunderland North East Lincolnshire South Tees Blackpool South Sefton Knowsley Stoke on Trent St Helens Halton

-

2,000

4,000

6,000

8,000

10,000



*





142

Lower GI problems (PBC 13B) - Non-elective spend per 1,000 overall weighted


NHS Blackpool CCG


4,974 5,121 5,430 5,485 5,553 6,302 6,305 6,479 6,482 6,508

7,232

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Blackpool South Tyneside North EastLincolnshire

Sunderland South Tees South Sefton Stoke on Trent Thanet Halton Knowsley St Helens

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000



Condition Group

143

Lower GI - Spend on non-elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

1,469

486

901

406

449

568

586

1,501

153

618

1,452

124

400

306

233

386

596

1,119

363

435

£3k (NSS)

£59k

£86k

£18k (NSS)

£41k

£36k (NSS)

£72k

£33k

0 500 1,000 1,500 2,000

Acute appendicitis

Unspecified appendicitis

Crohn's disease

Ulcerative colitis

Other and unspecifiednoninfective

gastroenteritis and colitis

Diverticular disease ofintestine with perforation

and abscess

Diverticular disease ofintestine without

perforation or abscess

Constipation

Abscess of anal and rectal regions

Nausea and vomiting



The majority of CCG spend and activity for acute and unspecified appendicitis is driven by procedures to remove the appendix (appendicectomy). The appendicectomy section of the pack (pages 259-266) provides further information and data on CCG performance. More information on Crohn's disease and ulcerative colitis can be found in the IBD section of the pack (pages 158-174).Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

144

Hepatobiliary problems - Non-elective spend

145

Hepatobiliary problems (13C): Non-elective spend


Charts in the following section will highlight variation in CCG non-elective spend for hepatobiliary problems (13C), andconditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell under hepatobiliary problems in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG's spend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bed day indicators are available in the data file for this pack.

For non-elective hepatobiliary spend, conditions make up 95% of the programme budget total nationally.

49 Adms £135k


Hepatobiliary problems (PBC 13C) - Non-elective spend per 1,000 age-

sex weighted population (SUS+ data) - 2017/18

8,513

6,054 7,601 8,023 8,610 8,697 9,027 9,557 9,865 9,954 10,450

-

2,000

4,000

6,000

8,000

10,000

12,000

Thanet South Tees North East Lincolnshire Blackpool Stoke on Trent Halton St Helens Sunderland South Tyneside South Sefton Knowsley

-

2,000

4,000

6,000

8,000

10,000

12,000



*





147

Hepatobiliary problems (PBC 13C) - Non-elective spend per 1,000 overall


NHS Blackpool CCG


6,826 6,980 7,162 7,391 7,502 7,687 8,840 8,849 9,023 9,425

10,253

-

2,000

4,000

6,000

8,000

10,000

12,000

Blackpool South Tees Thanet North EastLincolnshire

Stoke on Trent Halton St Helens Sunderland South Tyneside Knowsley South Sefton

-

2,000

4,000

6,000

8,000

10,000

12,000



Condition Group

148

Hepatobiliary - Spend on non-elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

3,453

1,954

1,127

1,067

240

282

2,341

2,151

929

1,044

110

187

£211k

£38k (NSS)

£4k (NSS)

£25k

£19k (NSS)

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500

Liver disease

Gallbladder disease

Bile duct stones

Acute pancreatitis

Cholangitis

Obstruction of bile duct



The majority of CCG non-elective inpatient spend for gallbladder disease is driven by procedures to remove the gallbladder (cholecystectomy). The cholecystectomy section of the pack (starting on page 209) provides a more detailed view of CCG performance in this area. Further information and data on liver disease can be found in the pathway on a page (pages 14-17), and the oesophageal varices, paracentesis and liver transplant section (pages 248-258). Note that liver disease condition indicators align with PHE's definition of liver disease, which includes admissions and deaths due to liver cancer.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

149

Other gastrointestinal problems - Non-elective spend

150

Other GI problems (13X): Non-elective spend


Charts in the following section will highlight variation in CCG non-elective spend for other GI problems (13X), and conditions within this programme budget category. For each area of expenditure two indicators have been produced; one using Secondary Uses Service Plus (SUS Plus) data extracted from the National Commissioning Data Repository (NCDR), and the other using data from the programme budgeting collection. For more information on the differences between these two datasets, please refer to page 26 in the programme budgeting dataset section.

A list of conditions and their ICD-10 codes are shown in the table below, along with total national spend and the % of spend that fell under other GI problems in 2017/18. Note that if this is not 100% in the table below, we would not expect all of a CCG's spend to map to this programme budgeting category. 100% of CCG spend is shown in the charts on the following pages. Bed day indicators are available in the data file for this pack.

For non-elective other GI spend, conditions make up 76% of the programme budget total nationally.


Other GI problems (PBC 13X) - Non-elective spend per 1,000 age-sex


7,043 6,249 6,831 7,016 7,067

8,098 8,517 9,030 9,054 9,228 9,935

-

2,000

4,000

6,000

8,000

10,000

12,000

Thanet North East Lincolnshire Sunderland Blackpool South Tyneside St Helens Stoke on Trent South Tees Halton Knowsley South Sefton

-

2,000

4,000

6,000

8,000

10,000

12,000



*





152

Other GI problems (PBC 13X) - Non-elective spend per 1,000 overall weighted


NHS Blackpool CCG


5,780 6,185 6,433 6,493 7,395 7,492 7,608 7,838 8,025 8,139

9,276

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000


Sunderland South Tyneside Halton Thanet Stoke on Trent St Helens Knowsley South Tees South Sefton

-

2,000

4,000

6,000

8,000

10,000

12,000



Condition Group

Further information and data on hernias can be found in the hernia section of the pack (pages 226-238). Further information and data on emergency gastroenteritis admissions can

be found in the following gastroenteritis section (pages 154-157).



153

Other GI - Spend on non-elective admissions (SUS+ data) - 2017/18How different

are we?

NHS Blackpool CCG

350

559

1,548

299

102

287

1,553

398

180

435

1,422

249

198

375

1,633

297

£34k

£22k

£24k (NSS)

£10k (NSS)

£19k (NSS)

0 500 1,000 1,500 2,000

Enterocolitis due to clostridium difficile

Viral and other specifiedintestinal infections

Infectious gastroenteritisand colitis, unspecified (all ages)

Inguinal hernia

Umbilical hernia

Vascular disorders of intestine

Paralytic ileus and intestinal obstruction without hernia

Ventral hernia



154

Emergency gastroenteritis admissions by age



155

A09: Infectious gastroenteritis and colitis, unspecifiedCost, activity and length of stay for emergency admissions (2017/18)

For 2017/18, non-elective CCG spend on infectious gastroenteritis and colitis was £84 million nationally. This makes it one of the highest cost GI conditions. It appears on page 153 of the packs.

Cost and admissions are driven by two contrasting demographic groups: infants and young children, and elderly people.

Despite being responsible for a lower % of admissions than those aged 0-4, those aged 85+ have a much greater cost associated with them.

As highlighted by the bottom chart, this age group typically have a far greater average length of stay. The next page explores these trends in more detail.



156

A09: Infectious gastroenteritis and colitis, unspecifiedSecondary diagnoses for emergency admissions where A09 is the primary diagnosis (2017/18)

The longer average lengths of stay amongst older patients can be linked into the fact that they are far more likely to have secondary diagnoses than younger patients.

Less than 60% of 0 to 4 year olds admitted as emergencies for infectious gastroenteritis and colitis receive a secondary diagnosis. In comparison, virtually all of those aged 70+ are coded with one.

In 2017/18, the secondary diagnosis associated with the greatest cost across all ages was acute renal failure, unspecified.

Further local analysis can help systems better understand how each cohort of patients is driving their spend and admissions.

For A09 emergency admissions with a secondary diagnosis, the chart above shows the diagnoses which have the greatest cost associated with them.



157

Gastroenteritis - Spend on non-elective admissions by age - 2017/18How different

are we?

NHS Blackpool CCG

1,548

3,559

621

1,136

3,172

5,088

1,422

1,832

366

803

3,299

8,545

£24k (NSS)

£16k

£6k

£35k

0 2,000 4,000 6,000 8,000 10,000

Infectious gastroenteritisand colitis, unspecified (all ages)

age 0-4 years

age 5-18 years

age 19-64 years

age 65-84 years

age 85+ years


per 1,000 specific age-sex weighted population

Section eight: Inflammatory bowel disease

159

Opportunities to maximise outcomes in IBDCrohn's Disease and Ulcerative Colitis are the two main forms of Inflammatory Bowel Disease (IBD), affecting more than 300,000 people in the UK. The chronic, fluctuating nature of IBD and the fact that it is most often diagnosed in the young (29.5 years old) has significant cost, resource and workforce implications for the NHS.

• Parts of the digestive system become swollen, inflamed and ulcerated causing severe pain, diarrhoea, malnutrition, bowel damage, fatigue and disability. IBD can also cause extra-intestinal manifestations: swollen joints, mouth ulcers, and eye, skin and liver problems.

• The lifetime medical costs associated with care can be comparable to heart disease or cancer. The annual cost of treating any patient with UC was estimated to be £3,084 (remission £1,693; relapse £2,903; severe relapse £10,760) and £6,156 for CD (£1,800 remission; £10,513 relapse) (BMJ, 2014).

• Varying standards of care further contribute to costs through inefficiency & poor outcomes. Conventional models of care will not meet rising demand.

• Timely diagnosis & rapid treatment improve outcomes. Delayed diagnosis is linked to higher incidence of surgery, risk of bowel perforation/sepsis, reduced response to medication & more expensive treatments.

• Much of outpatient activity is flare management, with 50% patients experiencing at least one relapse a year. Services face pressures from (possibly avoidable) unplanned admissions and in-patient stays.

• The specialist IBD nurse, as part of the multidisciplinary team, is key to delivering flare care, self-management & shared care, as well as reducing unnecessary admissions and outpatient attendances.

• Increasing use of biologics have led to a shift in care from symptom management to preventing disease progression. One year after starting a biologic, 30-50% of individuals can expect to be in clinical remission.

• However, surgery remains part of management with: 50%-70% with CD and 20-30% of UC having surgery.• Opportunities to self-manage, risk stratify patients and manage appropriate patients in primary care continue to be

underutilised.



https://www.crohnsandcolitis.org.uk/about-inflammatory-bowel-disease/crohns-disease

https://www.crohnsandcolitis.org.uk/about-inflammatory-bowel-disease/ulcerative-colitis

http://s3-eu-west-1.amazonaws.com/files.crohnsandcolitis.org.uk/Publications/PPR/ibd-standards.pdf

https://fg.bmj.com/content/early/2015/02/24/flgastro-2014-100514

https://www.crohnsandcolitis.org.uk/news/latest-ibd-audit-results-show-variation-in-care-for-patients

https://www.ecco-ibd.eu/publications/congress-abstract-s/abstracts-2014/item/p586-time-to-diagnosis-in-inflammatory-bowel-disease.html

https://www.nice.org.uk/guidance/qs81/chapter/Quality-statement-2-Multidisciplinary-team-support

https://www.researchgate.net/publication/12316728_Evaluation_of_the_effectiveness_of_a_specialist_nurse_in_the_management_of_inflammatory_bowel_disease_IBD

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872064/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872064/

160

Top tips for commissioners:• Alongside NHS RightCare packs, there are several data sets which are an excellent starting point when trying to understand the

needs of local populations and judging whether current provision and investment is achieving optimum outcomes.

• IBD Audit can be used to understand past performance against defined IBD Standards.

• IBD Registry (which combines the IBD dataset with routinely collected NHS data) is also an important data repository which is driving improvements in quality, safety and efficiency in areas such as biologic use and service responsiveness, and increasing clinicians understanding of their patient population and real world outcomes.

• Diagnostic waiting times and unnecessary tests are an issue for both patients and the NHS. Local referral pathways and faecalcalprotectin testing in primary care may present significant opportunities to unlock capacity in the system (endoscopy/outpatients), reduce costs (estimated potential savings of £55m-£266m nationally) and improve access to services.

• IBD nurses transform services; improving efficiency, patient experience and outcomes. The role has been found to reduce hospital visits by 38% & in-patient length of stay by 19%. Talk to your IBD service - do teams conform to the recommended workforce levels and do staff feel that the most is being made of their specialist nursing role in IBD services and/or the community?

• IBD patients experiencing a flare and waiting for treatment can deteriorate quickly- increasing costs (2-3 fold) associated with escalating treatment & workforce resourcing. Looking at what rapid access pathways and shared care protocols are available locally is an excellent starting point for exploring what opportunities exist to reduce avoid unplanned admissions, in-patient stays & pressures on outpatient services.

• Unsupported patients risk flaring. More people with IBD want to self-manage but face barriers to the necessary support or ‘activation’ both in secondary and primary care. It’s worth exploring whether the tools and resources to support self-management are being made available locally and are shared at each contact.

• The local IBD Patient Panel or creating a Patient Panel can be an excellent resource/partner when co-producing services, underpinned by principles outlined in My Crohn’s and Colitis Care.

• For more information &/or full slide deck email [email protected]

https://www.rcplondon.ac.uk/projects/ibd-programme

https://www.crohnsandcolitis.org.uk/news/latest-ibd-audit-results-show-variation-in-care-for-patients

https://ibdregistry.org.uk/benefits-of-joining-the-registry/

https://ibdregistry.org.uk/case-studies/

https://www.pcc-cic.org.uk/article/updated-guidance-help-gps-easily-diagnose-serious-bowel-conditions

https://www.pcc-cic.org.uk/article/updated-guidance-help-gps-easily-diagnose-serious-bowel-conditions

https://www.ncbi.nlm.nih.gov/pubmed/11007131

https://ibdregistry.org.uk/wp-content/uploads/2017/07/Modelling-Caseload-for-IBD-CNS-CCUK-report-2017.pdf

http://s3-eu-west-1.amazonaws.com/files.crohnsandcolitis.org.uk/Publications/PPR/ibd-standards.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/11/gastroenterology-elective-care-handbook.pdf

http://www.stmarkshospital.nhs.uk/about/ibd-patient-panel/

https://www.crohnsandcolitis.org.uk/about-inflammatory-bowel-disease/publications/my-crohns-and-colitis-care


161

Faecal calprotectin testing:Early identification and appropriate referral

Faecal calprotectin (FCP) is an innovative diagnostic test that supports GPs to accurately distinguish between irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). IBS is a functional disorder, whilst IBD is a chronic disease which can cause inflammation to the gut and any part of the digestive system, from the mouth to the anus, ulcers or other damage to thebowel. The two conditions are often confused, however, as they are symptomatically similar and people can have both. IBD delayed diagnosis is linked to higher incidence of surgery, increased risk of bowel perforation, reduced response to medication and more expensive treatments.

Faecal Calprotectin (FCP) is a protein secreted by the gut when it is inflamed, such as in IBD. If there is no inflammation, such as in IBS, calprotectin levels are normal meaning that there is no need for onward referral and unnecessary, invasive diagnostics which can be time consuming and costly. Clinicians should rule out IBD before diagnosing IBS. The cost of a gastroenterology referral to secondary care is approximately £666, whereas the cost of a FCP test is approximately £25.

Following a pilot into the effectiveness of FCP as a diagnostic test in primary care by Dr Turvill of York Teaching Hospital, Yorkshire & Humber Academic Health Science Network introduced a new FCP testing pathway to assist GPs in the diagnosis of IBS and IBD. Nine systems covering 240 GP practices have adopted the new pathway with an additional 11 systems undergoing implementation. Next steps include the spread and adoption of the pathway across other AHSNs and systems as this piece of work is now one of the AHSNs collaborative projects.

NICE recommends faecal calprotectin testing as an option for clinicians to distinguish between IBS and IBD and has published guidance in this area. An FCP working group was established by NHS England's Chief Scientific Office which produced a Consensus Paper. This paper includes a revised pathway and has been endorsed by NICE and is now used within their guidance.

Work is also on-going with the NHS BSA Pacific team to promote the work and to produce a model for measuring the benefits of implementing the pathway. Please see the case study on the Yorkshire and the Humber Academic Health Science Network Pacific and Y&HAHSN case study.

https://www.nice.org.uk/guidance/dg11

https://www.nice.org.uk/guidance/dg11/resources/endorsed-resource-consensus-paper-pdf-4595859614

https://www.nhsbsa.nhs.uk/sites/default/files/2018-06/YH AHSN Faecal Calprotectin Case Study 06 2018 (V2).pdf

162

Faecal calprotectin testing (cont.)

There are several benefits of faecal calprotectin testing for patients, commissioners and GPs:

For patients:

• Improvement of patient experience leading to greater confidence on their diagnosis.

• Quicker diagnosis and treatment decisions will help early identification of serious conditions and lead to improved outcomes.

For commissioners:

• Reduction in unnecessary referrals will mean a reduction in number of patients attending outpatient appointments prior to procedures and less investigations.

• Improved value for money resulting in financial savings.

For GPs:

• Reduction in the number of GP referrals to secondary specialist care.

• Gives clinicians more confidence in diagnosis of IBS without the need for secondary care intervention.

• Gives clinicians confidence in requesting appropriate investigations and referrals so that patients are seen in a timely way by the right healthcare professionals.

Resources and more information

• The Royal College of General Practitioners Clinical Innovation and Research Centre, in partnership with Crohn's and Colitis UK, has developed an Inflammatory Bowel Disease Toolkit (see ‘Diagnosing IBD and the use of faecal calprotectin’ section)

• AHSN Network has published a pathway/case study on FCP

• For more information about FCP and IBD, contact Crohn’s and Colitis UK at [email protected]

• NICE guidance and recommendations on FCP and the Chief Scientific Office working group’s consensus paper

http://www.rcgp.org.uk/clinical-and-research/resources/toolkits/inflammatory-bowel-disease-toolkit.aspx

http://atlas.ahsnnetwork.com/faecal-calprotectin-pathway/


https://www.nice.org.uk/guidance/dg11

https://www.nice.org.uk/guidance/dg11/resources/endorsed-resource-consensus-paper-pdf-4595859614

Identified patient count

Modelled estimated patient count

163

Please note this is only a rough estimate, with the average spend per patient figure assuming that there are no scripts missing for these patients. As such it should be treated with

caution, and combined with local knowledge and analysis. However, it provides useful context for the chart on the next page, which shows the rate of people prescribed

aminosalicylates in 2017/18 based solely on the known ‘Identified patient count’ figure.

This is a count of the number of patients prescribed a drug or appliance within your CCG, using the number of unique NHS Numbers recorded on prescriptions. The chart on the

following page shows the rate of people prescribed aminosalicylates within your CCG, and how this compares nationally and to your similar peers. This can be interpreted as the

number of patients within the 2017/18 financial year who are known to have had at least one prescription of this drug.

Aminosalicylates are drugs that minimise the degree of inflammation in the intestine and help the healing of damaged lining. They are commonly prescribed to treat mild to

moderate ulcerative colitis, and also some cases of Crohn’s disease. In the absence of Inflammatory Bowel Disease prevalence data, looking at the unique number of patients

prescribed aminosalicylates provides a picture of how many patients have mild to moderate ulcerative colitis in a CCG, and will also include a group Crohn's patients. Please note

this does not represent an accurate IBD prevalence figure, and should be triangulated with other datasets.

All prescriptions through the Electronic Prescription Service (EPS) will be included in this count, along with a high proportion of the printed paper scripts. However, for a number of

the printed paper scripts the NHS Number will not be attainable due to damage or being incorrect. Nationally, the data completeness of the ‘Identified patient count’ is about 90% for

all prescriptions.

The percentage of spend covered by the Identified patient count for aminosalicylates prescriptions in your CCG is 92%.

Due to the data quality issues with the ‘Identified patient count’ figures above, RightCare have estimated the additional number of patients who may have been prescribed a drug or

appliance i.e. the estimated number of patients missed from the ‘Identified patient count’, due to their NHS number not being attained. This has been calculated using the difference

in total spend on a drug or appliance, the spend captured by the identified patient count and the average spend per patient in your CCG (from the population captured in the

identified patient count).

Using the methodology above, it is calculated that an extra 96 patients were prescribed aminosalicylates in your CCG in 2017/18.

Aminosalicylates: Identified patient count data quality summary

1,031 96

Number of patients prescribedaminosalicylates

Number of additional patientsprescribed aminosalicylates(modelled)

0.6% 0.06%

% patients in CCG prescribedaminosalicylates

% patients in CCG prescribedaminosalicylates (modelled)

*

The above indicator shows the rate of unique patients known to have been prescribed an aminosalicylate in 2017/18. Please note that CCGs for which less than 90% of their

aminosalicylate cost can be attributed to a patient have been excluded due to data quality issues.

164

Primary Care Prescribing: Aminosalicylates: Identified patient count per 1,000


NHS Blackpool CCG


6.05.3 5.4 5.6 5.8 5.8 5.9 5.9 6.3 6.4 6.6

-

1

2

3

4

5

6

7

8

Sunderland South Tees South Sefton North EastLincolnshire

St Helens Knowsley South Tyneside Blackpool Thanet Stoke on Trent Halton

-

1

2

3

4

5

6

7

8

9



165

Irritable bowel disease elective spend summary

The treatment and care of Crohn’s disease and ulcerative colitis involves medical and surgical specialties, and a diverse range of patient sub-groups and interventions. As there is no curative treatment, most IBD patients require life-long drug treatment, which is limited in range and efficacy, and while the introduction of biologics is thought to be reducing volumes of surgery, surgical intervention remains a staple part of IBD management.

Elective spend for Crohn's and ulcerative colitis will include day case investigations (endoscopies - diagnostic, surveillance and monitoring purposes), day case drug treatment visits (biological drug treatments/iron infusions), and elective admissions for minor and major surgical procedures (for complications such as fistulas (abscesses), fissures, and bowel resections (permanent and temporary)). People living with Crohn’s and ulcerative colitis are also at risk of developing cancer, and therefore surveillance is recommended within this cohort (as per Nice guideline CG118).

While elective activities have been grouped together in the indicator, CCGs can perform their own analysis to investigate these different cohorts of patients, to better understand what is driving activity and identify opportunities for targeting improvement. Being able to understand differences between medical and surgical interventions will help to understand where variability in levels of diagnostics, drug therapies and planned surgery lie. Future NHS RightCare indicators will look to separate these out.

It is important to note that elective SUS spend data does not include biologics activity, such as subcutaneous biological drug treatments, and outpatient activity, which accounts for significant spend in IBD care. Relevant data regarding biologic use is part of the 2018 Quality Accounts and is collected by the IBD Registry, in which some, but not all providers currently participate. Alongside NHS RightCare packs, this data set is an excellent starting point when trying to understand the needs of local populations and judging whether current provision and investment is achieving optimum outcomes.

7 Adms

(NSS)£3k (NSS)


Elective spend for Crohn's disease will include day case investigations (endoscopies - diagnostic, surveillance and monitoring purposes), day case drug treatment visits (biological

drug treatments/iron infusions), and elective admissions for minor and major surgical procedures (for complications such as fistulas (abscesses), fissures, and bowel resections

(permanent and temporary)). It is important to note that elective SUS spend data does not include biologics activity, such as subcutaneous biological drug treatments, and

outpatient activity, which accounts for significant spend in IBD care.

NHS Blackpool CCG

Crohn's disease - Elective spend per 1,000 age-sex weighted population -

2017/18

669

444 625 654 670

873 994 1,021 1,033

1,121 1,236

-

200

400

600

800

1,000

1,200

1,400

St Helens South Tees Stoke on Trent Blackpool Halton South Sefton Knowsley Thanet North East Lincolnshire South Tyneside Sunderland

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800


England 755 Best or Lowest 5 653


Elective spend for ulcerative colitis will include day case investigations (endoscopies - diagnostic, surveillance and monitoring purposes), day case drug treatment visits

(biological drug treatments/iron infusions), and elective admissions for minor and major surgical procedures (for complications such as fistulas (abscesses), fissures, and bowel

resections (permanent and temporary)). It is important to note that elective SUS spend data does not include biologics activity, such as subcutaneous biological drug

treatments, and outpatient activity, which accounts for significant spend in IBD care.

NHS Blackpool CCG

Ulcerative colitis - Elective spend per 1,000 age-sex weighted population -

2017/18

332 361 431

531 548 567 579 624 677 693 741

-

100

200

300

400

500

600

700

800

900

Blackpool Stoke on Trent South Sefton North East Lincolnshire South Tyneside St Helens Halton Knowsley Thanet South Tees Sunderland

-

200

400

600

800

1,000

1,200



27 Bed

days

Higher elective bed day rates for Crohn's disease will be driven by higher rates of admissions and/or patients receiving surgical treatments which require a longer length of stay.

168

Crohn's disease - Elective bed days per 100,000 age-sex weighted population -

2017/18

NHS Blackpool CCG


112

62 87 96 99

136 152 159 163 172 196

-

50

100

150

200

250

St Helens Stoke on Trent South Tees Halton Blackpool Thanet South Sefton Knowsley South Tyneside North EastLincolnshire

Sunderland

-

50

100

150

200

250

300

350

400



Higher elective bed day rates for Ulcerative colitis will be driven by higher rates of admissions and/or patients receiving surgical treatments which require a longer length of stay.

169

Ulcerative colitis - Elective bed days per 100,000 age-sex weighted population -

2017/18

NHS Blackpool CCG


57 50 63

79 88 89 93 104 113 118

135

-

20

40

60

80

100

120

140

160

Stoke on Trent Blackpool South Sefton South Tyneside St Helens North EastLincolnshire

Thanet South Tees Halton Knowsley Sunderland

-

20

40

60

80

100

120

140

160

180

200



170

Irritable bowel disease non-elective spend summary

Crohn’s and ulcerative colitis are fluctuating, chronic conditions. 50% of patients report experiencing at least one flare a year and will require rapid intervention in order to avoid deterioration.

Patients with non-elective admissions can be grouped into those that may require surgery, those who do not require surgery but intensive medical therapy, and a combination of both. These can be different cohorts of patients with differing management needs. Due to small numbers, NHS RightCare is unable to publish indicators which segment patients into these different cohorts; however CCGs will be able to do this through local analysis.

Patients who have a length of stay of zero or shorter stays (0-3 days) represent potentially avoidable admissions. There are interventions that can be taken at the primary care level or by IBD clinical nurse specialists that can reduce shorter non-elective admissions and enable more appropriate outpatient attendances. Levels of emergency admissions can be an indication of blockages or shortfalls in: triage; access to diagnostics; rapid access (flare) pathways; supported self-management/patient education; and IBD management via shared care between primary and secondary care - which can be addressed.

Longer lengths of stay (4 days+) can indicate complex disease or high severity - an indication that unplanned care might be focusing on the most serious cases, or that patients are receiving suboptimal care in the community before being admitted. A review of local pathways for referrals for suspected IBD or flare management, and increasing access to advice via IBD helplines and/or IBD nurses may be worthwhile.

To more clearly understand the impact of unplanned care of IBD, it is worth bearing in mind that there are many emergency admissions coded with IBD as a secondary diagnosis in SUS/HES data, with complications of the disease (e.g. perianal abscess) in the primary position. This means that IBD activity is often significantly under reported. Research by the IBD Registry which tracked the patient journey, extracting and scrutinising both primary and secondary diagnosis (or co-morbidity) coding, found an uplift in ulcerative colitis related admissions of 80% that were previously were unaccounted for. Relevant coding can include: abdominal pain, anaemia, stoma malfunction, abscess, obstruction, structuring, nausea, vomiting, constipation, gastrointestinal infections or post-operative complications.



27 Adms £86k


To more clearly understand the impact of unplanned care of IBD, it is worth bearing in mind that there are many emergency admissions coded with IBD as a secondary diagnosis

in SUS/HES data, with complications of the disease (e.g. perianal abscess) in the primary position. This means that IBD activity is often significantly under reported.

NHS Blackpool CCG

Crohn's disease and ulcerative colitis - Non-elective spend per 1,000 age-


1,301

729 757 786 811 926 929 931 973 978 1,064

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Stoke on Trent Knowsley North East Lincolnshire Halton St Helens Thanet South Tyneside South Tees South Sefton Sunderland Blackpool

-

500

1,000

1,500

2,000



*

Due to small numbers, NHS RightCare is unable to publish indicators which segment patients into length of stay cohorts; however, CCGs can do this through local analysis. For

patients who have a length of stay of zero or shorter stays (0-3 days) there are interventions that can be taken at the primary care level or by IBD clinical nurse specialists that can

reduce length of stay and enable more appropriate outpatient attendances. Longer stays (4 days+) can indicate complex disease or high severity - an indication that unplanned

care might be focusing on the most serious cases, or that patients are receiving suboptimal care in the community before being admitted. Without knowing the cohort of patients

being treated, it cannot be said what an optimum average length of stay would be for a CCG, meaning this indicator has not been RAG rated and no opportunities calculated.

172

Crohn's disease and ulcerative colitis - Non-elective average length of stay (days) -

2017/18

NHS Blackpool CCG


7.15.4 5.5 5.6 5.6 5.7 6.2 6.3 6.5 6.8

8.0

-

2

4

6

8

10

12

Thanet Stoke on Trent Sunderland South Tyneside Knowsley South Sefton St Helens Halton South Tees Blackpool North EastLincolnshire

-

2

4

6

8

10

12



173 Bed

days

Higher non-elective bed day rates for Crohn's disease and ulcerative colitis will be driven by higher rates of admissions and/or patients receiving more complex surgical treatments

which require a longer length of stay.

173

Crohn's disease and ulcerative colitis - Non-elective bed days per 100,000 age-sex


NHS Blackpool CCG


327

173 201 247 252 265 270 283 284 309 346

-

100

200

300

400

500

600

Stoke on Trent Knowsley South Tees Sunderland North EastLincolnshire

Thanet South Sefton St Helens South Tyneside Blackpool Halton

-

100

200

300

400

500

600



3 Readms

High rates of emergency readmissions for Crohn's disease and ulcerative colitis patients, may reflect that patients are receiving a lower quality of care in hospital, poor community

care, premature discharge, poor discharge planning or saturated outpatient services which are unable to review patients soon after discharge. However, a number of unrelated

factors can affect the likelihood of readmission. CCGs with high rates of emergency readmissions are advised to use local data and intelligence to gain a better understanding of

their performance.

174

Crohn's disease and ulcerative colitis - Percentage with an emergency all-cause

readmission within 30 days of discharge - 2016/17 - 2017/18

NHS Blackpool CCG


4.1

2.33.0 3.4 3.8 3.9 4.4 4.8 4.9

6.7 7.0

-

1

2

3

4

5

6

7

8

9

10


Knowsley Halton Sunderland South Sefton Blackpool South Tees Thanet St Helens South Tyneside Stoke on Trent

-

1

2

3

4

5

6

7

8

9

10



175

Section nine: Procedures

176

Gastrointestinal procedures summary

The following section includes several sub-sections on CCG spend, activity and performance for gastrointestinal procedures. This includes:

• Endoscopies (pages 177-208)

• Cholecystectomies (pages 209-225)

• Hernias (pages 226-238)

• Bowel resections (pages 239-247)

• Oesophageal varices procedures, paracentesis and liver transplants (pages 248-258)

• Appendicectomies (pages 259-266)

• Haemorrhoid and other lower GI procedures (pages 267-272)

Indicators in these sections should be considered alongside relevant condition indicators shown earlier in the pack. It should be noted that the potential cost improvements from different classes of the data will overlap to some extent. For example, the costs of an inguinal hernia repair will be included in the procedure category ‘primary repair of inguinal hernia’, and also under the condition category ‘inguinal hernia’. Thus the potential cost improvement for a CCG is not achieved by adding together the potential savings from both indicators.

Procedure spend and activity opportunities require careful interpretation. Although it is possible that opportunities exist for costs to be reduced, in other instances more funding and resource may be required to deliver a better quality service. Working with secondary care providers, systems should use the data in this pack as a starting point for discussions about service quality and where potential savings and improvement opportunities may exist.

Although not included in the following section, bed day procedure indicators are also available in the data file for this pack.

177

Endoscopies

178

In 2014, NHS England requested that providers should record all endoscopy activity in the Commissioning Data Set flows that feed into the Secondary Uses Service (SUS) data warehouse. This included procedures performed as part of screening programmes not paid for by the National Tariff Payment System (Payment by Results). In cases when procedures took place as part of screening programmes, it was requested that activity was flagged so as to be excluded from PbR.

However, there are inconsistencies in how this guidance has been implemented by providers. This is especially true for the bowel scope screening programme, which offers a one-off flexible sigmoidoscopy to all 55 year olds. Analysis of national data shows that many providers are listing CCGs as responsible purchasers for bowel scope screening procedures, which is heavily skewing their reported spend and activity.

To tackle this issue, the flexible sigmoidoscopy 45-84 year old indicator (page 204) excludes all procedures performed on 55 year olds. 55 year olds are also excluded from calculations for the percentage of flexible sigmoidoscopies performed on under 45s (page 206).

CCGs are advised to triangulate indicators produced in SUS with other national databases such as the Diagnostics Waiting Times and Activity Collection, and their own local data. A national endoscopy database is in development, with data currently being submitted from over 130 hospitals. Once this has full national coverage, it should become the most effective means by which commissioners can explore their endoscopy spend and activity.

Endoscopy: SUS data summary

179

Gastroscopy summary

Gastroscopy is an investigation of the upper GI tract - oesophagus, stomach and duodenum (first part of the small intestine) using a flexible endoscope. Approximately 750,000 gastroscopies are performed in the NHS in England each year. Much of the demand for gastroscopy comes through referrals made by primary care. Diagnostic gastroscopy is used in any person presenting with:

• New onset dyspepsia if they are aged 55 years or over • New onset dyspepsia with ‘alarm’ symptoms, such as dysphagia, weight loss, upper GI bleeding,

vomiting and/or anaemia • ‘Alarm’ symptoms for upper GI cancer, such as dysphagia, weight loss, anaemia, upper GI bleeding

and/or persistent vomiting • Dyspepsia which has not responded to standard medical treatment

Indicators in the following pages show CCG activity for gastroscopies performed in an inpatient day case or outpatient setting. A non-elective indicator is also included. For elective day case and outpatient procedures, data includes all activity, and not just that which maps to the GI programme budgeting category.

Day case and outpatient indicators are broken down by three age bands: under 45s, 45-84 year olds, and over 85s. Upper GI cancer is rare in under 45s, meaning the number of patients undergoing gastroscopy procedures in this age band should be relatively low. Gastroscopies performed on the very elderly carry much greater risks of adverse effects than those performed on younger patients, meaning those aged 85+ are included as a stand-alone group.

180

Diagnostic day case and outpatient gastroscopies - Activity summary - 2017/18How different

are we?

NHS Blackpool CCG

1,045

387

1,936

1,734

1,334

526

2,428

1,997

0 500 1,000 1,500 2,000 2,500

All ages

age 0-44 years

age 45-84 years

age 85+ years



The chart above shows your CCG's activity for diagnostic gastroscopies performed in a day case or outpatient setting, and how this compares to the average of the 5 lowest CCGs in your similar 10. National distribution charts on the following pages provide a more detailed view of CCG performance for each of these indicators. For further information on diagnostic gastroscopies please see pages 98-102 and 109-111 of the 2017 Diagnostics Atlas of Variation: https://fingertips.phe.org.uk/profile/atlas-of-variation Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.


181

Gastroscopies (All PBCs) - Elective day case & outpatient activity per 100,000 age-sex weighted


NHS Blackpool CCG


1,045 1,134 1,250 1,330 1,417 1,539 1,573 1,584 1,682 1,737 1,851

-

500

1,000

1,500

2,000

2,500

Blackpool Thanet Sunderland Stoke on Trent South Tees South Tyneside North EastLincolnshire

South Sefton St Helens Halton Knowsley

-

500

1,000

1,500

2,000

2,500



Upper GI cancer is rare in under 45s, meaning the number of people undergoing gastroscopy procedures in this age band should be relatively low. CCGs with high activity rates

may want to perform their own local analysis to explore whether patients are being referred appropriately.

182

Gastroscopies (All PBCs) - Under 45s - Elective day case & outpatient activity per 100,000 age-sex


NHS Blackpool CCG


387 474 503 523 543 588 615 666 686 693 726

-

100

200

300

400

500

600

700

800

900

Blackpool Thanet Stoke on Trent Sunderland South Tees North EastLincolnshire

South Tyneside Halton St Helens South Sefton Knowsley

-

100

200

300

400

500

600

700

800

900



183

Gastroscopies (All PBCs) - 45-84 year olds - Elective day case & outpatient activity per 100,000 age-sex


NHS Blackpool CCG


1,936 2,034 2,275 2,414 2,612 2,804 2,853 2,893 3,046 3,193 3,386

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Blackpool Thanet Sunderland Stoke on Trent South Tees South Tyneside South Sefton North EastLincolnshire

St Helens Halton Knowsley

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000



Gastroscopies performed on the very elderly carry much greater risks of adverse effects than those performed on younger patients. CCGs with high activity rates may want to

perform their own local analysis to explore whether patients are being referred appropriately.

184

Gastroscopies (All PBCs) - 85 and overs - Elective day case & outpatient activity per 100,000 age-sex


NHS Blackpool CCG


1,734 1,451

1,902 2,085 2,092 2,456 2,608 2,692 2,721 2,789 2,871

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Sunderland Blackpool South Sefton Thanet South Tees South Tyneside Halton Knowsley Stoke on Trent St Helens North EastLincolnshire

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000



*

It is expected that CCGs with younger populations, will perform a higher percentage of diagnostic gastroscopies on under 45s. CCGs are advised to triangulate their performance

on this indicator with age-sex standardised activity rates for under 45s, shown on page 182, which accounts for differences in CCG population structures. As they provide a fairer

basis for comparison between CCGs, opportunities have only been calculated for under 45 endoscopy activity indicators.

185

Gastroscopies (All PBCs) - Percentage of elective day case & outpatient activity for under 45s - 2017/18

NHS Blackpool CCG


17.2 17.7 18.2 19.4 19.5 19.8 20.5 20.9 20.9 21.5 21.5

-

5

10

15

20

25


Thanet St Helens South Tyneside South Tees Halton Sunderland South Sefton Knowsley Stoke on Trent

-

5

10

15

20

25

30

35

40

45



5 Patients

Gastroscopies are one of 15 key diagnostic tests, for which the NHS Constitution states less than 1% of patients should wait more than 6 weeks. CCGs which achieve good

performance compared to their peers may still be missing this target. CCGs are therefore advised to examine their waiting list times in greater detail,


186

Percentage of waiting list patients who waited 6 or more weeks for a gastroscopy - 2017/18 (4 separate

months combined)

NHS Blackpool CCG

Source: NHS England - Diagnostics Waiting times and Activity data

1.50.0 0.0 0.5 0.8 1.2 2.2 2.5 2.5

16.1 17.0

-

5

10

15

20

25

South Tees South Tyneside Sunderland Stoke on Trent Thanet Blackpool Halton St Helens North EastLincolnshire

Knowsley South Sefton

-

5

10

15

20

25

30

35

40

45



Unlike day case and outpatient indicators, non-elective endoscopy indicators are limited to activity which maps to the gastrointestinal programme budgeting category. Nationally

in 2017/18, 67% of non-elective gastroscopy activity is attributed to PBC 13 - GI. PBC 03 - Disorders of blood has the next highest attribution of 7%.

187

Gastroscopy - Non-elective admissions per 100,000 age-sex weighted population - 2017/18

NHS Blackpool CCG


92 78

96 105 112 117 122 129 133 155 166

-

20

40

60

80

100

120

140

160

180

200

Sunderland Blackpool North EastLincolnshire

Thanet Stoke on Trent South Sefton South Tyneside St Helens Halton South Tees Knowsley

-

20

40

60

80

100

120

140

160

180

200



188

Colonoscopy summary

In colonoscopy an endoscope is used to investigate the lining of the colon (entire large bowel). As with other lower GI endoscopies, ruling out colorectal cancer is considered the most important reason for such an investigation, particularly because early diagnosis of colorectal cancer is vital in order to improve outcomes. Computed tomography (CT) colonoscopy is a relatively new radiological technique designed to image the colon. It is sometimes referred to as ‘virtual colonoscopy’ because a CT scanner and a computer are used to generate three-dimensional images of the colon.

Indicators in the following pages show variation in CCG activity for colonoscopies performed in an inpatient day case or outpatient setting, combined with CT colonoscopies. A non-elective indicator is also included. For elective day case and outpatient procedures, data includes all activity, and not just that which maps to the GI programme budgeting category.

Day case and outpatient indicators are broken down by three age bands: under 45s, 45-84 year olds, and over 85s. Colon cancer is rare in under 45s, meaning the number of patients undergoing colonoscopy procedures in this age band should be relatively low. Colonoscopies performed on the very elderly carry much greater risks of adverse effects than those performed on younger patients, meaning those aged 85+ are included as a stand-alone group.

Note also that day case and outpatient indicators have been benchmarked against the average of a CCG’s similar 10 peers, rather than the standard NHS RightCare approach of the average of the lowest 5. Nationally there is a drive for CCGs to be performing more colonoscopies, with the aim of increasing prevention and early detection of colon cancer. For these reasons, it would be inappropriate to compare CCG activity rates against a lowest 5 benchmark, and opportunity figures should be carefully interpreted.

CCGs with low colonoscopy activity rates should triangulate these with colon cancer indicators, to investigate whether low colonoscopy activity may be leading to poorer detection rates and outcomes. CCGs with high activity rates should undertake further local analysis, and investigate whether patients who are being referred for symptomatic testing could have been managed via alternative pathways. Inparticular, CCGs should look into their under 45 activity rates, and whether patients at low risk of bowel cancer are being tested through the Faecal Immunochemical Test (FIT), or faecal calprotectin testing is being used to aid the diagnosis of inflammatory bowel disease or irritable bowel syndrome where cancer is not suspected as per NICE guidance.

Also included is a barium enema activity indicator. More information on these procedures can be found underneath the charts on pages 189-199.



189

Diagnostic day case and outpatient colonoscopies and CT colonoscopies -

Activity summary - 2017/18 How different

are we?

NHS Blackpool CCG

999

287

2,025

628

1,340

390

2,655

1,815

0 500 1,000 1,500 2,000 2,500

All ages

age 0-44 years

age 45-84 years

age 85+ years



The chart above shows your CCG's activity for CT colonoscopies and diagnostic colonoscopies performed in a day case or outpatient setting, and how this compares to the average of your similar 10. Nationally there is a drive for CCGs to be performing more colonoscopies, with the aim of increasing prevention and early detection of colon cancer. For these reasons, these indicators use a similar 10 benchmark rather than a lowest 5, and opportunity figures should be carefully interpreted. National distribution charts on the following pages provide a more detailed view of CCG performance for each of these indicators. For further information on diagnostic colonoscopies and CT colonoscopies please see pages 90-97 of the 2017 Diagnostics Atlas of Variation: https://fingertips.phe.org.uk/profile/atlas-of-variation Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.


Nationally there is a drive for CCGs to be performing more colonoscopies, with the aim of increasing prevention and early detection of colon cancer. For these reasons, this

indicator uses a similar 10 benchmark rather than a lowest 5, and opportunity figures should be carefully interpreted.

190

Colonoscopies and CT colonoscopies (All PBCs) - Elective day case & outpatient activity per 100,000

age-sex weighted population - 2017/18

NHS Blackpool CCGSource: Colonoscopies: National Commissioning Data Repository (NCDR) – Hospital Admissions Databases, SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart). CT Colonoscopies: Diagnostic

Imaging Dataset (DID), NHS Digital

999 1,116 1,165 1,235 1,240 1,264 1,350 1,377 1,470 1,525

1,654

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Blackpool Sunderland South Tyneside South Sefton South Tees Thanet Knowsley St Helens Stoke on Trent Halton North EastLincolnshire

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000





Colon cancer is rare in under 45s, meaning the number of people undergoing colonoscopy procedures in this age band should be relatively low. CCGs with high activity rates may

want to perform their own local analysis to explore whether patients are being referred appropriately.

191

Colonoscopies and CT colonoscopies (All PBCs) - Under 45s - Elective day case & outpatient activity

per 100,000 age-sex weighted population - 2017/18



287 312 336 351 356 356 379 402 407 430

571

-

100

200

300

400

500

600

700

Blackpool South Tyneside St Helens Knowsley Sunderland Halton South Sefton Stoke on Trent Thanet South Tees North EastLincolnshire

-

100

200

300

400

500

600

700





192

Colonoscopies and CT colonoscopies (All PBCs) - 45-84 year olds - Elective day case & outpatient

activity per 100,000 age-sex weighted population - 2017/18

NHS Blackpool CCG

Source: Colonoscopies: National Commissioning Data Repository (NCDR) – Hospital Admissions Databases, SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart). CT Colonoscopies: Diagnostic


2,025 2,201 2,300 2,387 2,456 2,459 2,724 2,754

2,981 3,106 3,180

-

500

1,000

1,500

2,000

2,500

3,000

3,500

Blackpool Sunderland South Tyneside South Tees Thanet South Sefton Knowsley St Helens Stoke on Trent Halton North EastLincolnshire

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000





Colonoscopies performed on the very elderly carry much greater risks of adverse effects than those performed on younger patients. CCGs with high activity rates may want to

perform their own local analysis to explore whether patients are being referred appropriately.

193

Colonoscopies and CT colonoscopies (All PBCs) - 85 and overs - Elective day case & outpatient activity




628 994 1,085 1,205 1,325

1,853 1,887 2,163 2,255

2,598 2,782

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Blackpool Sunderland South Sefton Stoke on Trent South Tees Knowsley Thanet North EastLincolnshire

South Tyneside Halton St Helens

-

1,000

2,000

3,000

4,000

5,000

6,000



*

It is expected that CCGs with younger populations, will perform a higher percentage of diagnostic colonoscopies and CT colonoscopies on under 45s. CCGs are advised to

triangulate their performance on this indicator with age-sex standardised activity rates for under 45s, shown on page 191, which accounts for differences in CCG population

structures. As they provide a fairer basis for comparison between CCGs, opportunities have only been calculated for under 45 endoscopy activity indicators.

194

Colonoscopies and CT colonoscopies (All PBCs) - Percentage of elective day case & outpatient activity

for under 45s - 2017/18



13.111.4 12.4 12.9 13.7 14.2 14.5 15.5 15.8 16.2

17.7

-

2

4

6

8

10

12

14

16

18

20

St Helens Halton South Tyneside Blackpool Thanet Knowsley South Sefton Stoke on Trent Sunderland North EastLincolnshire

South Tees

-

5

10

15

20

25

30

35



*

CT colonoscopy is a relatively new radiological technique where a CT scanner and a computer are used to generate three-dimensional image of the colon. Unlike a standard

colonoscopy CT colonoscopy is minimally invasive because there is no need to introduce an endoscope into the colon to obtain the images, and is as effective in the initial

diagnosis of colorectal cancer as optic colonoscopy. As with other colonoscopy indicators a similar 10 benchmark is used, but no opportunities have been calculated. For further

information on CT colonoscopies please see pages 91 and 93-97 of the 2017 Diagnostics Atlas of Variation: https://fingertips.phe.org.uk/profile/atlas-of-variation

195

CT colonoscopies - Activity per 100,000 age-sex weighted population - 2017/18

NHS Blackpool CCGSource: Diagnostic Imaging Dataset (DID), NHS Digital

36 77 83 98 147 158

247 342 364

473 530

-

100

200

300

400

500

600

Blackpool Sunderland South Sefton South Tees Thanet North EastLincolnshire

South Tyneside Knowsley Stoke on Trent St Helens Halton

-

100

200

300

400

500

600

700

800



*

196

Colonoscopies and CT colonoscopies (All PBCs) - Percentage performed as CT colonoscopies -

2017/18



The 2017 Diagnostics Atlas of Variation states that variation in usage of CT colonoscopy compared to optic colonoscopy may be a consequence the availability of CT scanners

capable of producing CT colonoscopy images, the availability of radiologists skilled in interpreting CT colonoscopy scans, training opportunities for radiologists in CT colonoscopy

and access to CT colonoscopy, especially travelling distance to service provision. A similar 10 benchmark is used for this indicator, and no opportunities are calculated. CCGs

performing a low percentage of CT colonoscopies compared to optic colonoscopies, however, may want to explore if opportunities exist to increase access to CT colonoscopy.

3.86.9 7.0 8.0 9.9 12.6

21.724.6 24.7

33.4 35.4

-

5

10

15

20

25

30

35

40

Blackpool South Sefton Sunderland South Tees North EastLincolnshire

Thanet South Tyneside Stoke on Trent Knowsley Halton St Helens

-

10

20

30

40

50

60



The 2017 Diagnostics Atlas of Variation states that barium enema is a useful test only in a very small number of patients, and that all inappropriate requests need to be stopped.

See pages 20, 92 and 93 of the Atlas for further information: https://fingertips.phe.org.uk/profile/atlas-of-variation

197

Barium enema tests - Total planned and waiting list activity per 100,000 population - 2017/18

NHS Blackpool CCG


- - - 1 1 2 5 19

128

218

376

-

50

100

150

200

250

300

350

400

450

Blackpool Knowsley South Sefton St Helens South Tees Halton Stoke on Trent Sunderland South Tyneside Thanet North EastLincolnshire

-

50

100

150

200

250

300

350

400

450



2 Patients

Colonoscopies are one of 15 key diagnostic tests which the NHS Constitution states less than 1% of patients should wait more than 6 weeks for. CCGs which achieve good

performance compared to their peers may still be missing this target. CCGs are therefore advised to examine their waiting list times in greater detail,


198

Percentage of waiting list patients who waited 6 or more weeks for a colonoscopy - 2017/18 (4 separate

months combined)

NHS Blackpool CCG


1.70.0 0.5 0.5 0.84.5 6.7 7.8 9.4

20.124.9

-

5

10

15

20

25

30

35

South Tyneside Thanet South Tees Sunderland Blackpool North EastLincolnshire

St Helens Halton Stoke on Trent South Sefton Knowsley

-

10

20

30

40

50

60



17 Procs


in 2017/18, 62% of non-elective colonoscopy activity is attributed to PBC 13 - GI. PBC 02 - Cancer has the next highest attribution of 15%.

199

Colonoscopy - Non-elective admissions per 100,000 age-sex weighted population - 2017/18

NHS Blackpool CCG


14.8

2.7 4.36.1

8.1 8.7 9.4 10.8 11.214.4 15.1

-

5

10

15

20

25

Sunderland Thanet South Sefton St Helens Knowsley Halton South Tyneside South Tees North EastLincolnshire

Blackpool Stoke on Trent

-

5

10

15

20

25

30

35



200

Flexible sigmoidoscopy summary

In flexible sigmoidoscopy only the sigmoid colon (last part of the large bowel) and rectum is examined using a flexible endoscope. Flexible sigmoidoscopy is the preferred procedure in some clinical situations because sedation is not required, and it is quicker and carries less risk than colonoscopy. It is particularly useful if a patient has rectal bleeding, and is commonly used to investigate this condition.

Indicators in the following pages show CCG activity for flexible sigmoidoscopies performed in an inpatient day case or outpatient setting. A non-elective indicator is also included. For elective day case and outpatient procedures, data includes all activity, and not just that which maps to the GI programme budgeting category.

Day case and outpatient indicators are broken down by three age bands: under 45s, 45-84 year olds, and over 85s. Colon cancer is rare in under 45s, meaning the number of patients undergoing flexible sigmoidoscopy procedures in this age band should be relatively low. Flexible sigmoidoscopies performed on the very elderly carry much greater risks of adverse effects than those performed on younger patients, meaning those aged 85+ are included as a stand-alone group.

Analysis of national data shows that many providers are listing CCGs as responsible purchasers for bowel scope screening procedures, which is heavily skewing their reported spend and activity. To tackle this issue, the flexible sigmoidoscopy 45-84 year old indicator (page 204) excludes all procedures performed on 55 year olds. 55 year olds are also excluded from calculations for the percentage of flexible sigmoidoscopies performed on under 45s (page 206).

Note also that day case and outpatient indicators have been benchmarked against the average of a CCG’s similar 10 peers, rather than the standard RightCare approach of the average of the lowest 5. Nationally there is a drive for CCGs to be performing more flexible sigmoidoscopies, with the aim of increasing prevention and early detection of colon cancer. For these reasons, it would be inappropriate to compare CCG activity rates against a lowest 5 benchmark, and opportunity figures should be carefully interpreted.

CCGs with low flexible sigmoidoscopy activity rates should triangulate these with colon cancer indicators, to investigate whether low flexible sigmoidoscopy activity may be leading to poorer detection rates and outcomes. CCGs with high activity rates should undertake further local analysis, and investigate whether patients who are being referred for symptomatic testing could have been managed via alternative pathways. In particular, CCGs should look into their under 45 activity rates, and whether patients at low risk of bowel cancer are being tested through the Faecal Immunochemical Test (FIT), or faecal calprotectin testing is being used to aid the diagnosis of inflammatory bowel disease or irritable bowel syndrome where cancer is not suspected as per NICE guidance.

201

Diagnostic day case and outpatient flexible sigmoidoscopies - Activity summary -

2017/18 How different

are we?

NHS Blackpool CCG

349

147

622

672

447

211

765

899

0 200 400 600 800 1,000

All ages

age 0-44 years

age 45-84 years

age 85+ years



The chart above shows your CCG's activity for flexible sigmoidoscopies performed in a day case or outpatient setting, and how this compares to the average of your similar 10. Nationally there is a drive for CCGs to be performing more flexible sigmoidoscopies with the aim of increasing prevention and early detection of colon cancer. For these reasons, these indicators use a similar 10 benchmark rather than a lowest 5, and opportunity figures should be carefully interpreted. National distribution charts on the following pages provide a more detailed view of CCG performance for each of these indicators. For further information on flexible sigmoidoscopies please see pages 90-97 of the 2017 Diagnostics Atlas of Variation: https://fingertips.phe.org.uk/profile/atlas-of-variation Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.


Nationally there is a drive for CCGs to be performing more flexible sigmoidoscopies with the aim of increasing prevention and early detection of colon cancer. For these reasons,

this indicator uses a similar 10 benchmark rather than a lowest 5, and opportunity figures should be carefully interpreted.

202

Flexible sigmoidoscopies (All PBCs) - Elective day case & outpatient activity (excluding 55 year olds)


NHS Blackpool CCG


349

171 275 298 315 338 354

576 579

755 807

-

100

200

300

400

500

600

700

800

900

Stoke on Trent Sunderland South Tyneside Thanet South Tees Blackpool North EastLincolnshire

South Sefton Halton Knowsley St Helens

-

200

400

600

800

1,000

1,200





Colon cancer is rare in under 45s, meaning the number of people undergoing flexible sigmoidoscopy procedures in this age band should be relatively low. CCGs with high activity

rates may want to perform their own local analysis to explore whether patients are being referred appropriately.

203

Flexible sigmoidoscopies (All PBCs) - Under 45s - Elective day case & outpatient activity per 100,000


NHS Blackpool CCG


147 68

135 147 154 166 170

255 267 342

403

-

50

100

150

200

250

300

350

400

450

500

Stoke on Trent Thanet Sunderland Blackpool South Tees North EastLincolnshire

South Tyneside Halton South Sefton Knowsley St Helens

-

50

100

150

200

250

300

350

400

450

500





The bowel scope screening programme offers a one-off to all 55-year olds. Many providers are listing CCGs as responsible purchasers for bowel scope procedures in SUS, which

heavily skews their reported activity. For this reason, all procedures performed on 55-year olds have been removed from this indicator.

204

Flexible sigmoidoscopies (All PBCs) - 45-84 year olds (excluding 55 year olds) - Elective day case &

outpatient activity per 100,000 age-sex weighted population - 2017/18

NHS Blackpool CCG


622

305 447 494 552 578 595

985 1,019

1,318 1,362

-

200

400

600

800

1,000

1,200

1,400

1,600

Stoke on Trent Sunderland South Tyneside Thanet South Tees North EastLincolnshire

Blackpool South Sefton Halton Knowsley St Helens

-

500

1,000

1,500

2,000

2,500





Flexible sigmoidoscopies performed on the very elderly carry much greater risks of adverse effects than those performed on younger patients. CCGs with high activity rates may

want to perform their own local analysis to explore whether patients are being referred appropriately.

205

Flexible sigmoidoscopies (All PBCs) - 85 and overs - Elective day case & outpatient activity per 100,000


NHS Blackpool CCG


672

273 403 600 731 794

959 1,003 1,319 1,319

1,589

-

500

1,000

1,500

2,000

2,500

South Tyneside Stoke on Trent Sunderland Blackpool Thanet South Tees North EastLincolnshire

Halton South Sefton Knowsley St Helens

-

500

1,000

1,500

2,000

2,500

3,000



*

It is expected that CCGs with younger populations, will perform a higher percentage of diagnostic flexible sigmoidoscopies on under 45s. CCGs are advised to triangulate their

performance on this indicator with age-sex standardised activity rates for under 45s, shown on page 203, which accounts for differences in CCG population structures. As they

provide a fairer basis for comparison between CCGs, opportunities have only been calculated for under 45 endoscopy activity indicators.

206

Flexible sigmoidoscopies (All PBCs) - Percentage of elective day case & outpatient activity for under

45s - 2017/18

NHS Blackpool CCG


20.019.022.7 22.8 23.2 24.2 24.2 24.2 25.5 27.4 28.6

-

5

10

15

20

25

30

35

Thanet Blackpool South Sefton North EastLincolnshire

Stoke on Trent Halton South Tees St Helens Knowsley Sunderland South Tyneside

-

10

20

30

40

50

60

70



Flexible sigmoidoscopies are one of 15 key diagnostic tests which the NHS Constitution states less than 1% of patients should wait more than 6 weeks for. CCGs which achieve

good performance compared to their peers may still be missing this target. CCGs are therefore advised to examine their waiting list times in greater detail,


207

Percentage of waiting list patients who waited 6 or more weeks for a flexible sigmoidoscopy - 2017/18 (4

separate months combined)

NHS Blackpool CCG


0.30.0 0.0 0.0 0.72.8 3.0

5.1 5.49.2

15.9

-

5

10

15

20

25

South Tees South Tyneside Thanet Blackpool Sunderland Halton St Helens North EastLincolnshire

Stoke on Trent Knowsley South Sefton

-

5

10

15

20

25

30

35

40

45




in 2017/18, 79% of non-elective flexible sigmoidoscopy activity is attributed to PBC 13 - GI. PBC 02 - Cancer has the next highest attribution of 6%.

208

Flexible sigmoidoscopy - Non-elective admissions per 100,000 age-sex weighted population - 2017/18

NHS Blackpool CCG


18 13 14

19 25 25 28 29 30 30 33

-

5

10

15

20

25

30

35

40

45

50

Sunderland Stoke on Trent Blackpool Halton North EastLincolnshire

South Tees South Sefton St Helens Knowsley Thanet South Tyneside

-

10

20

30

40

50

60

70



Cholecystectomies

210

Cholecystectomy and gallstone disease - Overview

* Source: National Commissioning Data Repository (NCDR) – Hospital Admissions Databases, SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart)

Gallstone disease occurs when hard fatty or mineral deposits (gallstones) form in the gallbladder. About 15% of adults are thought to have gallstone disease, and the majority of these people experience no symptoms. Of adults with gallstone disease, however, there is still a sizeable proportion (around 20%) who have symptomatic gallstone disease. The symptoms of gallstone disease range from mild, non-specific symptoms that can be difficult to diagnose, to severe pain and/or complications that are often easily recognised as gallstone disease by healthcare professionals.

Surgery to remove the gallbladder, known as cholecystectomy, is the most common way to treat biliary pain or cholecystitis caused by gallstones and is one of the most commonly performed surgical procedures in the NHS, with 74,360 cholecystectomies performed in England in 2017/18.*

NICE recommends that people diagnosed with symptomatic gallbladder stones should be offered laparoscopic cholecystectomy (removal of the gallbladder through 'keyhole' surgery). Keyhole surgery allows patients to leave hospital sooner, recover faster and be left with smaller scars than an open procedure. Of all cholecystectomies performed in England in 2017/18, 96.7% were performed laparoscopically.*

NICE also recommends that people should be offered day-case laparoscopic cholecystectomy when this is performed as an elective planned procedure, unless their circumstances or clinical condition make an inpatient stay necessary. There is a best practice tariff to incentivise high quality and cost effective care of £1,909 for the day-case procedure compared with £1,726 for inpatient procedures (National tariff 2017–18, ‘GA10K: Laparoscopic Cholecystectomy, 19 years and over, with CC Score 0’). Out of all elective planned cholecystectomies performed in England in 2017/18, 57.5% were performed as day cases.*

https://www.nice.org.uk/guidance/cg188/chapter/1-recommendations

211

Cholecystectomy and gallstone disease - Early treatment of patients

The NICE quality standard on gallstone disease also states that adults with acute cholecystitis (inflammation of the gallbladder which is usally caused by gallstones) should have a laparoscopic cholecystectomy within one week of diagnosis. Despite this, there is wide variation in the management of these patients, with cholecystectomy rates within 10 days of firstadmission for acute cholecystitis ranging from 0% to 35% across England.

Early treatment through laparoscopic cholecystectomy benefits patients as they are far less likely to be readmitted to hospital at a later date with recurrent cholecystitis or gallstone pancreatitis. Preventing these readmissions also has long-term cost benefits to commissioners; the 2017 GIRFT report on General Surgery states that if all suitable patients underwent gallbladder surgery within 14 days of diagnosis the total cost savings would be £5 million.

The Cholecystectomy Quality Improvement Collaborative project (Chole-QuIC) is a project initiated by the Royal College of Surgeons, and aims for 80% of eligible, admitted patients* to receive their cholecystectomy within eight days of presentationat hospital. Further information can be found on the following page, as well as the project's webpage:

https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/service-standards/emergency-surgery/cholecystectomy-quality-improvement-collaborative

The following pages show CCG performance across a range of cholecystectomy indicators. Indicators are designed to provide a high-level view of CCG spend and activity, and should be combined with local knowledge and data to gain a more complete picture of how patients are being treated and mananged.

Indicators on pages 213-216 have been produced using patient-level analysis of Secondary Uses Service data, and provide a view of the pathways patients have been following prior to having a cholecystectomy. Indicators on pages 217-224 provide a view of CCG spend and performance solely for the spell in which patients had a cholecystectomy.

* Patients with acute biliary pain / cholecystitis or gallstone pancreatitis who are assessed as medically fit for surgery and choose to have surgery on an urgent basis.

https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/service-standards/emergency-surgery/cholecystectomy-quality-improvement-collaborative/

212

The Royal College of Surgeons are moving into the second phase of a project that aims to reduce variation and improve the quality of care for patients with acute gallstone disease in hospitals.

BackgroundBetween 2016 and 2018, the RCS Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) supported 13 hospitals to improve care for patients with acute gallstone disease.

Their soon to be published evaluation papers demonstrate that participating hospitals substantially improved outcomes for patients by significantly reducing time to surgery for patients needing an emergency cholecystectomy. They also identified the key factors that enabled hospitals to succeed and overcome challenges to improvement, including the importance of structured support available from participation in an improvement collaborative.

Extended ReachIn 2019 they are planning to launch CholeQuIC-ER. This will offer the opportunity for hospitals across England and Wales to radically improve outcomes for patients with gallstone disease by implementing the learning from Chole-QuIC.

This next phase will use proven quality improvement methods and the experience of previous Chole-QuIC sites to support clinicians and managers to drive improvements to care for their cholecystectomy patients. Participating hospital teams will share ideas and best practice and learn how to overcome challenges through regular national collaborative events plus individual coaching to help them on their improvement journey.

If you are interested in joining the CholeQuIC-ER please email: [email protected]

Cholecystectomy quality improvement collaborative

https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/service-standards/emergency-surgery/cholecystectomy-quality-improvement-collaborative/


213

Cholecystectomy - Patient pathways prior to procedure - 2017/18

NHS Blackpool CCG

60

27

10

3

55

26

15

5

0 10 20 30 40 50 60 70

Elective cholecystectomy with no previous emergency admission

Elective cholecystectomy witha previous emergency admission

Non-elective cholecystectomywith no previous emergency

admission

Non-elective cholecystectomy with a previous emergency

admission


Percent (%)The above chart looks at those patients who had a cholecystectomy with a primary diagnosis of severe symptomatic gallstone disease in 2017/18, and provides a high-level view on the pathways they followed prior to having a cholecystectomy. For the 18 months before a cholecystectomy (split out by elective and non-elective procedures), it shows what proportion of patients were admitted as an emergency with severe symptomatic gallstone disease, and how this compares to your CCG's similar 10. Note that in cases where CCGs in a similar 10 have had their values suppressed, the sum of the similar 10 values will be greater than 100%. Those who have an emergency admission across their whole course of treatment (the final three groups on the chart above) represent a distinct cohort of patients, who should be receiving early access to a cholecystectomy following their initial admission. The following three pages will now provide a more detailed view on the pathways which these patients are following from their initial emergency admission to having a cholecystectomy.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.

*

The indicator above measures the average time from patients' first emergency admission for severe symptomatic gallstone disease, to the end of the spell in which they had a

cholecystectomy. The earlier a cholecystectomy is performed following an emergency admission for severe symptomatic gallstone disease, the less potential there is for recurrent

cholecystitis or gallstone pancreatitis. CCGs are advised to triangulate data for this indicator with average number of emergency admissions prior to cholecystectomy, and average

length of stay across their whole course of treatment, to build up a picture of whether opportunities may be being missed for patients to have a cholecystectomy at an earlier

date. As these indicators should be viewed in relation to each other they have not been RAG rated, with no opportunities calculated.

214

Average number of days to cholecystectomy (for patients who have had an emergency admission for

severe symptomatic gallstone disease in the previous 18 months) - 2017/18

NHS Blackpool CCG


97 59 65 78

98 124 128 131 148 156 170

-

50

100

150

200

250

Stoke on Trent South Tyneside Sunderland Blackpool South Sefton Halton Knowsley St Helens North EastLincolnshire

South Tees Thanet

-

50

100

150

200

250

300



*

For patients with an emergency admission across their whole course of treatment, the indicator above measures the average number of emergency admissions before the spell in

which they had a cholecystectomy. CCGs are advised to triangulate data for this indicator with average time to surgery, and average length of stay across their whole course of

treatment, to build up a picture of whether opportunities may be being missed for patients to have a cholecystectomy at an earlier date. As these indicators should be viewed in

relation to each other they have not been RAG rated, with no opportunities calculated. Note that in cases when patients have an emergency cholecystectomy with no previous

emergency admissions, their number of previous emergency admissions are recorded as zero.

215

Average number of previous emergency admissions (for cholecystectomy patients who have had an

emergency admission for severe symptomatic gallstone disease in the previous 18 months) - 2017/18

NHS Blackpool CCG


0.8

0.5 0.60.8 0.9 0.9 1.0 1.0 1.0 1.1 1.2

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Stoke on Trent South Tyneside Sunderland Blackpool South Sefton Halton Knowsley St Helens North EastLincolnshire

Thanet South Tees

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8



*

The indicator above measures the average length of stay from when patients had their first emergency admission for severe symptomatic gallstone disease, to the end of the spell

in which they had a cholecystectomy. CCGs are advised to triangulate data for this indicator with average time to surgery, and average number of emergency admissions prior to

cholecystectomy, to build up a picture of whether opportunities may be being missed for patients to have a cholecystectomy at an earlier date. As these indicators should be

viewed in relation to each other they have not been RAG rated, with no opportunities calculated. Note that when patients are admitted as day cases, this is recorded as a zero

length of stay, rather than 0.5 which is used in NHS RightCare bed day indicators.

216

Average total length of stay (for patients who had a cholecystectomy and an emergency admission for

severe symptomatic gallstone disease in the previous 18 months) - 2017/18

NHS Blackpool CCG


5.6

3.9 4.14.9 5.2

6.0 6.1 6.26.9 7.2 7.3

-

1

2

3

4

5

6

7

8

9

10

South Tyneside Sunderland South Tees Thanet Blackpool Halton Stoke on Trent St Helens North EastLincolnshire

Knowsley South Sefton

-

2

4

6

8

10

12



217

Cholecystectomy - Percentage of procedures performed by admission type -

2017/18

NHS Blackpool CCG

51

35

14

44

37

19

0 10 20 30 40 50 60 70

Day case

Elective non-day case

Emergency


Percent (%)

The chart above shows what percentage of CCG cholecystectomies were performed in an elective day case, elective non-day case, and non-elective setting in 2017/18, and how this compares to the average of their similar 10 peers. Note that in cases where CCGs in a similar 10 have had their values suppressed, the sum of the similar 10 values will be greater than 100%. NICE guidance states that people should be offered day-case laparoscopic cholecystectomy when this is performed as an elective planned procedure, unless their circumstances or clinical condition make an inpatient stay necessary. Although emergency cholecystectomies have longer average lengths of hospital stay and cost than elective procedures, performing a cholecystectomy in the same spell that a patient was admitted with symptomatic gallstone disease removes the risk of recurrent cholecystitis or gallstone pancreatitis. National distribution charts on the following pages show rates of CCG spend for each of these procedure types, along with an overall spend indicator.Error bars represent 95% confidence intervals. NHS RightCare opportunities that are not statistically significantly different to the benchmark are labelled as ‘NSS’. Further analysis to investigate these opportunities could include time series analysis, triangulation with other data sources or viewing alongside other related indicators.


Cholecystectomy - Spend per 1,000 age-sex weighted population -

2017/18

2,808 2,605 3,013 3,073 3,359 3,563

4,222 4,236 4,366 4,487

5,456

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Thanet Blackpool South Tees South Sefton St Helens North East Lincolnshire Knowsley Stoke on Trent Halton Sunderland South Tyneside

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000



11 Adms

(NSS)£22k (NSS)


Cholecystectomy - Elective day case spend per 1,000 age-sex weighted


NICE guidance states that people should be offered day-case laparoscopic cholecystectomy when this is performed as an elective planned procedure, unless their circumstances

or clinical condition make an inpatient stay necessary. CCGs will want to consider their performance alongside their spend on elective inpatient stay procedures (see page 220)

and the proportion of procedures performed by different admission type (see page 217).

1,232 879 997 1,115 1,274 1,278 1,310 1,416 1,442

2,016 2,079

-

500

1,000

1,500

2,000

2,500

3,000

South Sefton Thanet Stoke on Trent Blackpool St Helens North East Lincolnshire South Tees Knowsley Halton Sunderland South Tyneside

-

500

1,000

1,500

2,000

2,500

3,000




Cholecystectomy - Elective non-day case spend per 1,000 age-sex


NICE guidance states that people should be offered day-case laparoscopic cholecystectomy when this is performed as an elective planned procedure, unless their circumstances

or clinical condition make an inpatient stay necessary. CCGs will want to consider their performance alongside their spend on elective day case procedures (see page 219), and

the proportion of procedures performed by different admission type (see page 217).

858

466

893 1,028 1,254 1,261 1,323 1,333 1,416 1,417

1,692

-

500

1,000

1,500

2,000

2,500

Stoke on Trent Blackpool South Sefton Sunderland South Tyneside Thanet North East Lincolnshire St Helens South Tees Knowsley Halton

-

500

1,000

1,500

2,000

2,500

3,000



1 Adms

(NSS)£3k (NSS)


Cholecystectomy - Non-elective spend per 1,000 age-sex weighted


Non-elective cholecystectomies will see patients being treated in the same spell that they were admitted for symptomatic gallstone disease. This reduces the potential for

recurrent events (recurrent cholecystitis or gallstone pancreatitis) during the wait for surgery. Unlike other non-elective spend indicators published in NHS RightCare packs, it is

therefore not judged that CCGs with high rates of spend are performing 'worse' than their similar peers. Note that non-elective cholecystectomies have a higher tariff than

elective procedures, which will create larger opportunities being listed in the box in the top right-hand corner.

723 282 327

744 955

1,231 1,300 1,392 1,452

2,133

2,653

-

500

1,000

1,500

2,000

2,500

3,000

3,500

South Tees Thanet Blackpool St Helens North East Lincolnshire Halton South Sefton Knowsley Sunderland South Tyneside Stoke on Trent

-

500

1,000

1,500

2,000

2,500

3,000

3,500



*

Average length of stay following a cholecystectomy will be strongly influenced by the proportion of procedures CCGs perform by different admission type, with CCGs performing a

higher percentage of cholecystectomies as elective day cases likely to have a lower average length of stay (see page 219). Without knowing the cohort of patients being treated, it

cannot be said what an optimum average length of stay would be for a CCG, meaning this indicator has not been RAG rated and no opportunities calculated.

222

Cholecystectomy - Average length of stay (days) - 2017/18

NHS Blackpool CCG


1.21.0 1.0 1.1 1.3 1.4 1.5 1.7 1.72.0

2.7

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Thanet South Tees Sunderland Blackpool St Helens Halton South Tyneside Knowsley North EastLincolnshire

South Sefton Stoke on Trent

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0



*

223

Cholecystectomy - Non-elective average length of stay (days) - 2017/18

NHS Blackpool CCG


High average lengths of stay for patients treated with an emergency cholecystectomy could indicate that patients are in poorer health upon admittance to hospital, and are

subsequently take longer to recover following their procedure. Opportunities may also be being missed to discharge patients at an earlier date. Without knowing the cohort of

patients being treated, it cannot be said what an optimum average length of stay would be for a CCG, meaning this indicator has not been RAG rated and no opportunities

calculated. CCGs with high average lengths of stay, however, are advised to use local data and intelligence to gain a better understanding of their performance.

7.1

4.2 4.45.4 5.7 6.3 6.4 6.5 7.0 7.5 7.9

-

2

4

6

8

10

12

Sunderland South Tyneside Knowsley North EastLincolnshire

Thanet Stoke on Trent South Sefton St Helens Blackpool Halton South Tees

-

2

4

6

8

10

12

14



4 Readms

High rates of emergency readmissions for patients receiving a cholecystectomy, may be indicate that patients are receiving a lower quality of care in hospital or are being

prematurely discharged. However, a number of factors unrelated to the quality of hospital care can affect the likelihood of readmission. CCGs with high rates of emergency

readmissions are advised to use local data and intelligence to gain a better understanding of their performance.

224

Cholecystectomy - Percentage with an emergency all-cause readmission within 30

days of discharge - 2016/17 - 2017/18

NHS Blackpool CCG


9.4

6.6 7.2 7.3 8.09.2 9.3 9.4 9.5 10.1

11.6

-

2

4

6

8

10

12

14

16

South Tyneside Sunderland North EastLincolnshire

Thanet Halton Stoke on Trent St Helens Blackpool Knowsley South Tees South Sefton

-

2

4

6

8

10

12

14

16

18



40 Adms £109k


An ERCP is an endoscopy of the bile duct and pancreas. It is commonly used to remove gallstones from the bile duct, and may be used before or after a cholecystectomy.

Identifying and removing gallstones which have moved into the bile duct greatly reduces the risk of future complications, such as biliary sepsis or pancreatitis. It is therefore

unlikely that opportunities will exist for CCGs to reduce access to the procedure, and CCGs with low spend and activity will want to explore whether this is leading to poorer

outcomes further along the pathway.

Nationally in 2017/18, 59% of activity was elective. Similar groups of patients are treated via elective and non-elective procedures, so an overall spend indicator has been

produced. Nationally in 2017/18, 79% of activity was attributed to PBC 13 - GI and 8% to PBC 02 - Cancer. This indicator is limited to procedures attributed to PBC 13.

NHS Blackpool CCG

Endoscopic retrograde cholangiopancreatography (ERCP) - Spend per

1,000 age-sex weighted population - 2017/18

1,818

778

1,223 1,298 1,420 1,581 1,638 1,647 1,827 1,875

2,216

-

500

1,000

1,500

2,000

2,500

3,000

North East Lincolnshire Stoke on Trent Sunderland Thanet St Helens South Tyneside South Tees Blackpool Halton South Sefton Knowsley

-

500

1,000

1,500

2,000

2,500

3,000



Hernias

RCS/BHS Hernia Report on patient access to inguinal hernia surgery: https://www.rcseng.ac.uk/news-and-events/media-centre/press-releases/hernia-surgery-

rationing/. See also the RCS/BHS 2016 Groin Hernia Commissioning Guide.


Primary repair of inguinal hernia - Spend per 1,000 age-sex weighted


1,273 1,288 1,346 1,382 1,420 1,634 1,754 1,768 1,785 1,794

1,976

-

500

1,000

1,500

2,000

2,500

Blackpool South Sefton Stoke on Trent Knowsley South Tees St Helens South Tyneside Sunderland Halton North East Lincolnshire Thanet

-

500

1,000

1,500

2,000

2,500

3,000




Primary repair of inguinal hernia - Elective spend per 1,000 age-sex


1,149 1,194 1,259 1,368 1,526 1,577 1,583 1,637 1,649 1,765

-

500

1,000

1,500

2,000

2,500

South Sefton Blackpool Stoke on Trent Knowsley South Tees St Helens North East Lincolnshire South Tyneside Halton Sunderland Thanet

-

500

1,000

1,500

2,000

2,500


No Data


Suppression has been applied to CCGs who have a non-elective activity less than 5, as these low numbers could be revealed by subtracting the elective figure from the total. For these CCGs, it can be inferred that overall spend rates (see previous page) will be very close to their elective spend. CCGs will want to consider their elective spend rates alongside their policies for performing inguinal hernias, and whether these correspond to Royal College of Surgeons/British Hernia Society guidance.RCS/BHS Hernia Report on patient access to inguinal hernia surgery: https://www.rcseng.ac.uk/news-and-events/media-centre/press-releases/hernia-surgery-rationing/. See also the RCS/BHS 2016 Groin Hernia Commissioning Guide.

1 Adms £3k

RCS/BHS Hernia Report on patient access to inguinal hernia surgery: https://www.rcseng.ac.uk/news-and-events/media-centre/press-releases/hernia-surgery-

rationing/. See also the RCS/BHS 2016 Groin Hernia Commissioning Guide.


Primary repair of inguinal hernia - Non-elective spend per 1,000 age-sex


124

52

108 118 122 148 152 171

208 216

-

50

100

150

200

250

300

350

400

South Sefton South Tees St Helens Sunderland Knowsley Blackpool Halton Stoke on Trent South Tyneside Thanet North East Lincolnshire

-

100

200

300

400

500

600

700

800


No Data


21 Procs

The 2016 Royal College of Surgeons and British Hernia Society Groin Hernia Commissioning Guide recommends that at least 70% of all procedures are performed as day cases.

Note that CCG opportunities and RAG ratings for this indicator are based on the highest 5 benchmark, rather than this target. However, CCGs will want to consider their

performance against both their similar peers and the 70% target when exploring if opportunities exist to increase their day case rate.

230

Primary repair of inguinal hernia - Percentage of all procedures performed as a day

case - 2017/18

NHS Blackpool CCG


66.954.0

67.6 71.7 72.5 73.7 77.7 78.0 79.2 80.7 82.8

-

10

20

30

40

50

60

70

80

90

100

Thanet Blackpool South Sefton St Helens North EastLincolnshire

South Tyneside Halton Knowsley Stoke on Trent South Tees Sunderland

-

10

20

30

40

50

60

70

80

90

100

Other CCGs Blackpool Similar 10 National Highest 5 BHS Target


*

231

Primary repair of inguinal hernia - Percentage of all procedures performed

laparoscopically - 2017/18

NHS Blackpool CCG


The 2016 RCS and BHS Groin Hernia Commissioning Guide states that groin hernias in women should preferentially be repaired laparoscopically, and the laparoscopic approach

may be beneficial in patients at risk of chronic pain. It also states that whilst the majority of meta analyses conclude that the incidence and severity of pain is lower after

laparoscopic compared to open repair, there are limitations in the studies used. For these reasons, the highest 5 CCGs are used as the benchmark for this indicator, but it is not

RAG rated and no opportunities are calculated.

39.9

2.9 5.5 5.7 5.9 6.1 6.1 9.3 12.617.2

21.2

-

5

10

15

20

25

30

35

40

45

50

St Helens North EastLincolnshire

Halton South Tees South Tyneside South Sefton Knowsley Thanet Sunderland Stoke on Trent Blackpool

-

10

20

30

40

50

60

70

80



*

The 2016 RCS and BHS Groin Hernia Commissioning Guide states that when possible, bilateral inguinal hernias should be repaired laparoscopically from a cost-utility and patient

perspective. However, laparoscopic repair will not be appropriate for all bilateral hernias. For this reason, the highest 5 CCGs are used as the benchmark for this indicator, but it is

not RAG rated and no opportunities are calculated.

232

Primary repair of inguinal hernia - Percentage of bilateral procedures performed

laparoscopically - 2015/16-2017/18

NHS Blackpool CCG


56.9

36.8 40.047.0 52.0 52.2 53.3 53.6 53.8 59.4 64.3

-

10

20

30

40

50

60

70

80

90

St Helens South Sefton Sunderland Stoke on Trent South Tees South Tyneside North EastLincolnshire

Thanet Blackpool Halton Knowsley

-

10

20

30

40

50

60

70

80

90

100



1 Readms

High rates of emergency readmissions for patients having primary repairs of inguinal hernias, may be indicate that patients are receiving a lower quality of care in hospital or are

being prematurely discharged. However, a number of factors unrelated to the quality of hospital care can affect the likelihood of readmission. CCGs with high rates of emergency

readmissions are advised to use local data and intelligence to gain a better understanding of their performance.

233

Primary repair of inguinal hernia - Percentage with an emergency all-cause

readmission within 30 days of discharge - 2016/17 - 2017/18

NHS Blackpool CCG


4.43.1 3.7 4.2 4.2 4.3 4.3 4.7

6.0 6.6

-

2

4

6

8

10

12


St Helens Thanet Halton Sunderland South Tyneside Stoke on Trent Blackpool South Tees Knowsley South Sefton

-

2

4

6

8

10

12

14


No Data


Nationally in 2017/18, 93% of activity was elective.


Repair of recurrent inguinal hernia - Spend per 1,000 age-sex weighted


92 63 81 84

106 117 127 169 172

198

-

50

100

150

200

250

300

350

South Sefton Knowsley North East Lincolnshire South Tees Blackpool South Tyneside Halton Thanet Sunderland Stoke on Trent St Helens

-

50

100

150

200

250

300

350

400


No Data


19 Adms £27k


Primary repair of umbilical hernia - Elective spend per 1,000 age-sex


467

242 258 340 373 390 432

497 504 505 580

-

100

200

300

400

500

600

700

800

Stoke on Trent St Helens Knowsley South Sefton South Tees South Tyneside Blackpool Sunderland Halton Thanet North East Lincolnshire

-

200

400

600

800

1,000




Primary repair of umbilical hernia - Non-elective spend per 1,000 age-sex


69 61 104 109

137 154 195 203

-

50

100

150

200

250

300

350

400

South Tyneside Halton Knowsley Sunderland Blackpool St Helens Thanet South Tees Stoke on Trent North East Lincolnshire South Sefton

-

100

200

300

400

500


No Data No Data No Data


*

Mesh has been suggested as the optimal repair for most hernias when recurrence is the primary endpoint. However, mesh may be associated with increased complications for the

patient. For umbilical hernias, a commonly used alternative to mesh is suture repair. This indicator has not been RAG rated, a similar 10 benchmark used, and no opportunities

calculated.

237

Primary repair of umbilical hernia - Percentage of elective procedures repaired

using mesh - 2017/18

NHS Blackpool CCG


42.6

20.731.4 34.0 38.8

44.9 48.8 50.062.8 63.2

73.0

-

10

20

30

40

50

60

70

80

90

South Tees Sunderland Thanet Stoke on Trent Blackpool South Tyneside Knowsley South Sefton Halton North EastLincolnshire

St Helens

-

10

20

30

40

50

60

70

80

90

100



1 Adms

(NSS)£2k (NSS)


A ventral hernia is a bulge through an opening in the muscles on the abdomen. Many ventral hernias are incisional hernias, which develop at the site of a previous surgery. As

this indicator incorporates a wide range of hernia types, which require different treatments, careful local analysis is needed to understand the different cohorts of patients

being treated.

Nationally in 2017/18, 88% of activity was elective.

NHS Blackpool CCG

Repair of ventral hernia - Spend per 1,000 age-sex weighted population -

2017/18

810 676 763 779 841 937 1,016 1,086 1,096 1,133

1,335

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

South Tyneside South Tees Stoke on Trent Blackpool Thanet North East Lincolnshire Knowsley Halton Sunderland St Helens South Sefton

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800



Bowel resections

240

Bowel resection

A bowel resection is an operation where the surgeon removes a section of bowel (intestine) due to it being damaged or diseased. Depending on the cause, either the large intestine or small intestine or occasionally both can be affected. Patients can present acutely unwell as an emergency with obstruction or perforation; or electively, for example for a tumour or diverticula disease. During the procedure the surgeon will check the bowel and remove the appropriate section. The two cut ends will be stitched or stapled together to form a continuous tube again, or the end may be brought out onto the abdominal wall surface as a stoma. This may be either temporarily or permanently. If it is likely that a patient will require a stoma they should see a stoma specialist nurse before and after the procedure. The amount of bowel removed can vary, but the surgeon will leave as much of the bowel as possible.

Large bowel resections are used for a variety of conditions including intestinal cancer blockages of the bowel and inflammatory bowel disease such as ulcerative colitis and Crohn’s disease. A common reason for small bowel resection is bowel damage due to adhesive or hernia related obstruction. Please note that this focus pack concentrates on procedures where there is no colorectal cancer.

Resections can be done by either laparoscopic (key hole) or open surgery. The British Society of Gastroenterologists have published guidelines for the management of inflammatory bowel disease in adults and states that laparoscopic surgery appears ‘safe and feasible’ in the management of Crohn’s disease, if surgery is required, and the benefits ‘seem to be related to an improvement in early postoperative recovery, a reduction in wound complication and a cosmetic advantage’.

Due to issues with small numbers, indicators in the following section group together all small bowel and colorectal non-cancer bowel resection. However, CCGs may want to perform local analysis to better understand the types of procedures being performed, and the cohorts of patients being treated. Nationally, colorectal resections for gastrointestinal conditions (excluding cancer) are most commonly used to treat patients with diverticular disease (2,991 procedures performed in 2017/18) and Crohn’s disease and ulcerative colitis (2,848 procedures performed in 2017/18), with colon resections (7,047 procedures performed in 2017/18) being more common than rectal resections (4,470 procedures performed in 2017/18).*

Dr Praminthra Chitsabesan, Colorectal Surgeon, York Teaching Hospitals NHS Foundation Trust

* Source: National Commissioning Data Repository (NCDR) – Hospital Admissions Databases, SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart)

https://www.bsg.org.uk/resource/guidelines-for-the-management-of-inflammatory-bowel-disease-in-adults.html


Colorectal resection - Elective spend per 1,000 age-sex weighted


Nationally in 2017/18, 19% of activity is attributed to PBC 13 - GI and 78% to PBC 02 - Cancer. All elective colorectal resection indicators are limited to procedures attributed to

PBC 13, and a sub-set of procedures which map to the cancer programme budgeting category that are used to remove benign tumours.

354

682 689 744 809 885 933 945 989 1,019 1,100

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Blackpool Stoke on Trent South Sefton Thanet St Helens Knowsley Sunderland Halton South Tees North East Lincolnshire South Tyneside

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800



*

242

Colorectal resection - Percentage of elective procedures performed

laparoscopically - 2017/18

NHS Blackpool CCG


In its guidelines for the management of IBD in adults, the British Society of Gastroenterologists states that laparoscopic surgery appears ‘safe and feasible’ in the management of

Crohn’s disease, if surgery is required, and the benefits ‘seem to be related to an improvement in early postoperative recovery, a reduction in wound complication and a cosmetic

advantage’. Factors such as BMI >35, previous operations, complexity of disease, severe lung or heart disease may also preclude a laparoscopic procedure. For these reasons the

highest 5 CCGs are used as the benchmark for this indicator, but as it cannot be said what proportion of patients could have been treated laparoscopically, it has not been RAG

rated and no opportunities calculated. CCGs where a low percentage of patients are treated laparoscopically, however, may want to explore whether opportunities exist for more

patients to receive laparoscopic procedures.

40.0 43.8 44.4 48.3 51.9 52.063.2 69.4 72.4 74.4

-

10

20

30

40

50

60

70

80

90

Blackpool Stoke on Trent Halton South Sefton North EastLincolnshire

St Helens Knowsley Thanet South Tees South Tyneside Sunderland

-

10

20

30

40

50

60

70

80

90

100


No Data


*

243

Colorectal resection - Elective average length of stay (days) - 2017/18

NHS Blackpool CCG


High elective average lengths of stay may be a consequence of CCGs performing more complicated colorectal resections associated with longer stays in hospitals, such as total and

transverse colectomies. Opportunities may also be missed to discharge patients at earlier dates. Without knowing the cohort of patients being treated, it cannot be said what an

optimum average length of stay would be for a CCG, meaning this indicator has not been RAG rated and no opportunities calculated. CCGs are advised to use local data and

intelligence to gain a better understanding of the factors driving their average lengths of stay.

7.95.4 5.9

7.3 7.4 7.7 7.9 8.1 8.4 8.610.8

-

2

4

6

8

10

12

14

16

Thanet South Tees South Tyneside South Sefton Stoke on Trent Knowsley Blackpool St Helens Halton North EastLincolnshire

Sunderland

-

5

10

15

20

25

30



8 Adms £69k


Colorectal resection - Non-elective spend per 1,000 age-sex weighted


Nationally in 2017/18, 61% of activity is attributed to PBC 13 - GI and 31% to PBC 02 - Cancer. All non-elective colorectal resection indicators are limited to procedures attributed

to PBC 13, and a sub-set of procedures which map to the cancer programme budgeting category that are used to remove benign tumours.

1,304

791 865 970 1,026 1,065 1,081 1,152 1,179 1,442

2,089

-

500

1,000

1,500

2,000

2,500

3,000

3,500

South Tyneside Thanet Sunderland North East Lincolnshire Knowsley South Tees Stoke on Trent St Helens Blackpool Halton South Sefton

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000



*

245

Colorectal resection - Non-elective average length of stay (days) - 2017/18

NHS Blackpool CCG


High non-elective average lengths of stay may be a consequence of CCGs performing more complicated colorectal resections associated with longer stays in hospitals, such as

total and transverse colectomies. They may also indicate that opportunities are being missed to discharge patients at earlier dates. Without knowing the cohort of patients being

treated, it cannot be said what an optimum average length of stay would be for a CCG, meaning this indicator has not been RAG rated and no opportunities calculated. CCGs are

advised to use local data and intelligence to gain a better understanding of the factors driving their average lengths of stay.

21.3

10.514.3

18.2 18.3 19.9 20.2 20.4 20.6 21.1 21.8

-

5

10

15

20

25

30

Thanet South Tyneside Knowsley Sunderland South Tees Stoke on Trent Halton St Helens North EastLincolnshire

Blackpool South Sefton

-

10

20

30

40

50

60



£4k (NSS)


Small bowel resection - Spend per 1,000 age-sex weighted population -

2017/18

Nationally in 2017/18, 74% of activity is attributed to PBC 13 - GI and 14% to PBC 02 - Cancer. This indicator is limited to procedures attributed to PBC 13, and a sub-set of

procedures which map to the cancer programme budgeting category that are used to remove benign tumours. Of the procedures this indicator focusses on, nationally in

2017/18, 83% of activity was non-elective.

894 697

841 859 978 992 1,012 1,055 1,171 1,178 1,336

-

500

1,000

1,500

2,000

2,500

South Tyneside Thanet St Helens Blackpool Sunderland Halton North East Lincolnshire South Tees Stoke on Trent South Sefton Knowsley

-

500

1,000

1,500

2,000

2,500

3,000




Closure of ileostomy - Spend per 1,000 age-sex weighted population -

2017/18

After a bowel resection, a patient may require a temporary or permanent stoma. Closure of ileostomy refers to the closure of a temporary ileostomy. Information and data on

CCG stoma prescribing can be found in the stoma prescribing section (pages 79-88).

176 119 167 201 226 228

310 386 416

499 537

-

100

200

300

400

500

600

700

800

900

1,000

South Tees Stoke on Trent Blackpool Thanet South Tyneside Sunderland North East Lincolnshire South Sefton St Helens Halton Knowsley

-

200

400

600

800

1,000

1,200

1,400



Oesophageal varices procedures, paracentesis and liver transplants

249

Oesophageal varices and ascites procedures

Procedures to treat bleeding from oesophageal varices, and to drain fluid from the abdomen (paracentesis), arecommonly performed due to complications of advanced chronic liver disease/cirrhosis.

Varices

Varices are blood vessels which form as a consequence of high pressure in the portal vein, the main blood supply to the liver. They are most commonly found in the lower oesophagus although they can occur throughout the GI tract. Varices are at risk of bleeding which can vary in severity from a small ooze to a life threatening haemorrhage.

Several procedures can be used to stop the bleeding and reduce the risk of recurrence including drug treatment, using endoscopy to insert a small band around the base of the varix to control the bleeding, injecting sclerosant material into the varices to induce blood clotting to stop the bleed and using a stent.

Ascites

Ascites are the accumulation of fluid in the abdomen which develops as a consequence of portal hypertension. They can cause a variety of symptoms including abdominal discomfort, poor appetite, shortness of breath, indigestion, nausea, and reduced mobility. Ascitic fluid can become infected which can be life-threatening unless treated.

To relieve the symptoms of ascites it is necessary to remove excess fluid from the abdomen which can be done using treatment with diuretic drugs or by a large volume paracentesis procedure. The procedure involves insertion of a needle and tube into the peritoneal cavity to drain the fluid. It is a safe procedure and less than 1% of people experience a significant side-effect. Large volume paracentesis is a quick (6 hours) method of removing fluid from the abdomen and may be used when diuretic treatment has ceased to have an effect, causes side-effects or may take a long time to have an effect.



250

Oesophageal varices and ascites procedures (cont.)

Public Health England's Atlas of Variation in Liver Disease (September 2017) provides several options for action for local health systems to reduce emergency admissions for both conditions.

When planning service improvement or development to reduce emergency admissions for oesophageal varices, commissioners, clinicians and service providers need :

• to review the emergency admission rate for oesophageal varices in the locality

• to identify opportunities for improving the early diagnosis of cirrhosis and other types of liver damage

• to improve the prevention and treatment of oesophageal varices

• to review the clinical management of and configuration of services for liver disease to ensure close collaboration among the different disciplines – hepatology, diagnostic pathology and radiology services, interventional radiology and liver surgery including resection and transplantation

When planning service improvement or development to reduce emergency admissions for paracentesis procedures, commissioners, clinicians and service providers need:

• to review the emergency admission rate for paracentesis in the locality

• to identify opportunities for establishing day case paracentesis procedures

• to consider discussing advance care planning with those patients not suitable for transplantation

To prevent ascites involves good management of liver disease, including aspects of self-management:

• dietary - reducing salt intake, and changing the type and amount of food eaten and number of times a day food is eaten (snacking on small amounts)

• abstinence from alcohol


43 Adms £31k


Paracentesis procedure - Elective spend per 1,000 age-sex weighted


Elective spend on paracentesis procedures should be considered alongside non-elective spend and the percentage of procedures which are performed as emergencies (shown

on the following two pages). Patients can be managed as planned day cases but in many services, they get repeatedly readmitted as emergencies, often staying in hospital for

several days while they have their paracentesis procedure. High rates of elective spend may therefore indicate good practice which is helping prevent emergency hospital

admissions.

309

94 104 125 153

265 270 272 303

411 422

-

100

200

300

400

500

600

South Sefton South Tees South Tyneside Stoke on Trent Thanet Halton North East Lincolnshire St Helens Blackpool Knowsley Sunderland

-

100

200

300

400

500

600

700

800



16 Adms £74k

For more information on paracentesis procedures see pages 159-161 of the 2017 Liver Disease Atlas of Variation: https://fingertips.phe.org.uk/profile/atlas-

of-variation


Paracentesis procedure - Non-elective spend per 1,000 age-sex


1,635

1,020 1,072 1,296 1,401 1,459 1,582 1,623

1,940 2,072 2,178

-

500

1,000

1,500

2,000

2,500

3,000

North East Lincolnshire Thanet South Tees Stoke on Trent Knowsley Sunderland South Sefton Blackpool South Tyneside St Helens Halton

-

500

1,000

1,500

2,000

2,500

3,000


England 943 Best or Lowest 5 1,250

2 Procs

Large volume paracentesis involves insertion of a needle and tube into the peritoneal cavity to drain fluid which has accumulated because of cirrhosis. Patients can be managed as

planned day cases but in many services, they get repeatedly readmitted as emergencies, often staying in hospital for several days while they have their paracentesis procedure. A

high percentage of elective procedures may therefore indicate that patients are receiving a higher quality of care, and avoiding preventable emergency hospital admissions. CCGs

with suppressed values will be performing a high percentage of procedures as emergencies.

253

Paracentesis procedure - Percentage of all procedures performed as an

emergency - 2017/18

NHS Blackpool CCG


45.338.5 41.5 42.4 45.6

52.664.6 68.8

76.9 79.5 81.4

-

10

20

30

40

50

60

70

80

90

100

Thanet Sunderland Knowsley Blackpool North EastLincolnshire

St Helens Halton Stoke on Trent South Tyneside South Sefton South Tees

-

20

40

60

80

100

120




Oesophageal varices procedure - Elective spend per 1,000 age-sex


Elective spend on oesophageal varices procedures should be considered alongside non-elective spend and the percentage of procedures which are performed as emergencies

(shown on the following two pages). Unless oesophageal varices bleed, they do not generate any other signs or symptoms. If bleeding occurs, it is characteristically severe and

can be life-threatening. High rates of elective spend may therefore indicate good practice which is helping prevent emergency hospital admissions.

23 32 32 43 46

63

94 105

-

20

40

60

80

100

120

140

160

180

Knowsley South Sefton Thanet Blackpool Sunderland South Tees Halton St Helens North East Lincolnshire Stoke on Trent South Tyneside

-

50

100

150

200

250




3 Adms £14k

For more information on oesophageal varices procedures see pages 156-158 of the 2017 Liver Disease Atlas of Variation:



Oesophageal varices procedure - Non-elective spend per 1,000 age-sex


281 135 183 189 212

310 340 370 448 451

770

-

200

400

600

800

1,000

1,200

Thanet Halton North East Lincolnshire South Tyneside Blackpool Stoke on Trent Knowsley Sunderland St Helens South Sefton South Tees

-

200

400

600

800

1,000

1,200



5 Procs

Unless oesophageal varices bleed, they do not generate any other signs or symptoms. If bleeding occurs, it is characteristically severe and can be life-threatening. A high

percentage of elective procedures may therefore indicate that patients are receiving a higher quality of care, being diagnosed and treated before their varices bleed. CCGs with

suppressed values will want to investigate whether this is due to low numbers of elective or non-elective procedures.

256

Oesophageal varices procedure - Percentage of all procedures performed as an

emergency - 2017/18

NHS Blackpool CCG


59.1

23.536.8 42.0 42.1

48.6

66.777.8

-

10

20

30

40

50

60

70

80

90

100

Knowsley South Sefton Thanet South Tyneside Halton Stoke on Trent North EastLincolnshire

St Helens Blackpool Sunderland South Tees

-

10

20

30

40

50

60

70

80

90

100




*

Liver transplantation is a recognised therapy for some patients with end-stage chronic liver disease, however, most people dying from liver failure are not suitable candidates for

liver transplantation. Note that a similar 10 benchmark has been used for this indicator, and no opportunities calculated. See pages 142-145 of the 2017 Liver Disease Atlas of

Variation for more information: https://fingertips.phe.org.uk/profile/atlas-of-variation

257

Rate of adults added to liver transplant waiting list per 100,000 population -

2012/13 - 2017/18

NHS Blackpool CCG

Source: NHS Blood and Transplant, Organ donation and transplant statistics

2.0

1.1 1.3 1.41.8

2.3 2.3 2.5 2.6 2.6 2.9

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Thanet South Tees Sunderland North EastLincolnshire

Blackpool South Tyneside South Sefton Halton Knowsley St Helens Stoke on Trent

-

1

2

3

4

5

6



*

The 2017 Liver Disease Atlas of Variation states that when planning service improvement or development for liver transplantation, commissioners, clinicians and service providers

could identify whether there are high liver mortality rates but low transplant rates in the locality, review care pathways for patients with liver disease, review criteria for selection

onto a transplant list, and where possible, provide transplant assessment services locally, rather than requiring the patient to travel. Note that a similar 10 benchmark has been

used for this indicator, and no opportunities calculated. See pages 142-145 of the 2017 Atlas for more information: https://fingertips.phe.org.uk/profile/atlas-of-variation

258

Adult liver transplant rate per 100,000 population - 2012/13 - 2017/18

NHS Blackpool CCG

Source: NHS Blood and Transplant, Organ donation and transplant statistics

1.51.2 1.3 1.4 1.7 1.9 2.0 2.2 2.4 2.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Thanet South Tees Sunderland North EastLincolnshire

Blackpool South Sefton St Helens Knowsley South Tyneside Halton Stoke on Trent

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0


No Data


Appendicectomies

260

Appendicitis and appendicectomy

Appendicitis is acute inflammation and swelling of the appendix. Appendicitis accounts for more than 40,000 hospital admissions in England every year and is one of the most common causes of abdominal pain in young adults and children in the UK. Appendicectomy (surgical removal of the appendix) is the treatment of choice in secondary care for people with appendicitis, as if left untreated the appendix can become gangrenous and burst, causing potentially life threatening complications.

The commonest cause of appendicitis is thought to occur when the entrance to the appendix becomes blocked, usually by a facecolith (a hard stone made of faeces). Appendicitis is a surgical emergency that requires immediate hospital assessment and management conditions that cause similar symptoms. Appendicitis can be simple or complex with features of an abscess or a mass.

For simple acute appendicitis, the Royal College of Surgeons recommends key hole surgery (laparoscopic appendicectomy) where not contraindicated and where technically feasible, as it has been proven to reduce the complication rate, postoperative pain, hospital stay, time to normal activity and work, outside of hospital cost and risk of negative appendicectomy.

More complex appendicitis may need more investigations, radiological drainage of abscesses and prolonged courses of antibiotics with a longer admission. However the 2017 Getting it Right First Time report on General Surgery also recommends that opportunities exist to more promptly discharge patients following a simple appendicectomy. It is calculated that if all providers were able to discharge patients two days after the procedure, this would free up 30,000 bed days nationally, with an associated cost reduction of £8.5 million.



http://gettingitrightfirsttime.co.uk/wp-content/uploads/2017/07/GIRFT-GeneralSurgeryReport-Aug17v1.pdf

Nationally in 2017/18, 99% of activity was non-elective.


Appendicectomy where the primary diagnosis is acute appendicitis - Spend per 1,000 age-


1,325 1,079 1,091

1,367 1,588 1,611 1,743 1,769 1,816 1,904

2,204

-

500

1,000

1,500

2,000

2,500

3,000

South Sefton South Tees Blackpool South Tyneside North East Lincolnshire Knowsley St Helens Sunderland Stoke on Trent Thanet Halton

-

500

1,000

1,500

2,000

2,500

3,000

3,500




Royal College of Surgeons Paediatric Emergency Appendicectomy Commissioning Guide (2015): https://www.rcseng.ac.uk/library-and-publications/rcs-

publications/docs/paediatric-emergency-appendicectomy/


Appendicectomy where the primary diagnosis is acute appendicitis - Paediatrics (0-16) -

Spend per 1,000 age-sex weighted population - 2017/18

1,413 1,211 1,252 1,413 1,797 1,819 1,898 2,056 2,189

2,467 2,756

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

South Tees South Sefton Blackpool South Tyneside St Helens Stoke on Trent North East Lincolnshire Sunderland Knowsley Thanet Halton

-

1,000

2,000

3,000

4,000

5,000

6,000



1 Adms

(NSS)£2k (NSS)



Appendicectomy where the primary diagnosis is acute appendicitis - Adults (17+) - Spend


1,300 1,036 1,064

1,350 1,471 1,515 1,697 1,730 1,767 1,821

2,071

-

500

1,000

1,500

2,000

2,500

3,000

South Sefton South Tees Blackpool South Tyneside Knowsley North East Lincolnshire Sunderland St Helens Thanet Stoke on Trent Halton

-

500

1,000

1,500

2,000

2,500

3,000

3,500



*

264

Appendicectomy where the primary diagnosis is acute appendicitis - Percentage of all procedures

performed laparoscopically - 2017/18

NHS Blackpool CCG


The RCS Commissioning guide for emergency general surgery (2014) states that laparoscopic appendicectomy is recommended over open appendicectomy in all patient groups

where not contraindicated and where technically feasible, with laparoscopy reducing the complication rate, postoperative pain, hospital stay, time to normal activity and work,

outside of hospital cost and risk of negative appendicectomy. For this reason, the highest 5 CCGs are used as the benchmark for this indicator, but because it cannot be said what

proportion of patients could have been treated laparoscopically it has not been RAG rated and no opportunities calculated. CCGs with a low percentage of patients treated

laparoscopically, will want to use local data and knowledge to understand the reasons for this.

29.6

59.671.1 74.0 75.0 76.4 80.0 83.8 91.8 92.5 96.4

-

20

40

60

80

100

120

Blackpool Halton St Helens Thanet North EastLincolnshire

South Sefton Knowsley South Tees South Tyneside Stoke on Trent Sunderland

-

20

40

60

80

100

120



*

265

Appendicectomy where the primary diagnosis is acute appendicitis - Average length of stay (days) -

2017/18

NHS Blackpool CCG


GIRFT's National Speciality Report into General Surgery (2017) states that if all providers could match the performance of those with the shortest length of stay (where nearly half

of patients discharged within two days of admission), then more patients could return home earlier and over 30,000 bed days freed up for other patients. It calculates that the

bed day savings could result in a cost reduction of £8.5 million. This indicator has therefore been RAG rated, but for consistency with other length of stay indicators no

opportunities have been calculated. CCGs with high average lengths of stay are advised to use local data and intelligence to explore whether opportunities exist to discharge

patients at an earlier date.

2.92.5 2.6 2.7

3.2 3.2 3.2 3.5 3.5 3.5 3.7

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Sunderland Thanet South Tyneside Blackpool Halton South Sefton Stoke on Trent South Tees North EastLincolnshire

Knowsley St Helens

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5



3 Readms

High rates of emergency readmissions for patients having appendicectomies, may indicate that patients are receiving a lower quality of care in hospital or are being prematurely

discharged. However, a number of factors unrelated to the quality of hospital care can affect the likelihood of readmission. The 2017 GIRFT report on General Surgery states that

if providers with high 30-day emergency readmission rates following appendicectomy could reduce their rates to the national average, this would free up £5.8 million worth of

bed days. CCGs with high rates of emergency readmissions are advised to use local data and intelligence to gain a better understanding of their performance.

266

Appendicectomy where the primary diagnosis is acute appendicitis - Percentage with an emergency all-

cause readmission within 30 days of discharge - 2016/17 - 2017/18

NHS Blackpool CCG


9.8

5.4 5.8 5.97.7 8.3 8.6 8.9 9.8 10.7 11.6

-

2

4

6

8

10

12

14

16

18

20

Thanet St Helens North EastLincolnshire

Sunderland Stoke on Trent South Tees Knowsley South Sefton Blackpool South Tyneside Halton

-

5

10

15

20

25



Haemorrhoid and other lower gastrointestinal procedures



268

Haemorrhoids

Haemorrhoids, also known as piles, are swellings containing enlarged blood vessels found inside or around the rectum and anus. NICE advices that admission or referral to secondary care should be arranged if:

• The diagnosis is unclear or a serious pathology is suspected.• The person does not respond to conservative treatment.• There are severe symptoms that cannot be managed in primary care.• There are recurrent symptoms that do not respond to primary care treatment

The suspected cancer pathway referral (for an appointment within two weeks) should be used if anal or colorectal cancer is suspected.

Secondary care treatments for haemorrhoids may be non-surgical or surgical, depending on the haemorrhoids themselves. The most commonly performed non-surgical treatment is rubber band ligation, where a band is applied to the base of the haemorrhoid, which causes the strangulated haemorrhoid to become necrotic, fibrose and shrink. NICE recommends this as the best available outpatient treatment of haemorrhoids. Recurrence rates are high but complications low and it is an easy and cost-effective procedure.

Surgical treatments for larger more complex haemorrhoids include haemorrhoidectomy (surgical removal of haemorrhoids), stapled haemorrhoidectomy, and haemorrhoidal artery ligation. About 10% of people will require surgery to alleviate their symptoms. The British Association of Day Surgery advises that most of these should be performed as day cases.



https://cks.nice.org.uk/haemorrhoids


NICE Clinical Knowledge Summary on haemorrhoids: https://cks.nice.org.uk/haemorrhoids#!topicsummary


Open haemorrhoidectomy - Spend per 1,000 age-sex weighted population - 2017/18

58 85 86 93 108 127

149 168 171 200

228

-

50

100

150

200

250

300

350

Blackpool Stoke on Trent South Tyneside South Sefton Sunderland North East Lincolnshire Halton St Helens South Tees Knowsley Thanet

-

50

100

150

200

250

300

350

400

450

500




CCGs should consider their spend on rubber band ligation and injection of sclerosing substance into haemorrhoid alongside their activity rates. As is discussed in more detail on

the following page, procedures performed in an outpatient setting have a much lower cost associated with them, meaning CCGs with low spend rates may still be performing a

high volume of outpatient procedures compared to day care procedures, and vice versa. Raw activity figures for this indicator are provided in this pack’s data file.

NHS Blackpool CCG

Rubber band ligation and injection of sclerosing substance into haemorrhoid - Elective and

outpatient spend per 1,000 age-sex weighted population - 2017/18

135 101 113 165

217 333 377 378 384

440

587

-

100

200

300

400

500

600

700

800

Thanet North East Lincolnshire Blackpool Stoke on Trent St Helens South Tees Knowsley Halton South Tyneside Sunderland South Sefton

-

200

400

600

800

1,000

1,200



*

271

Rubber band ligation and injection of sclerosing substance into haemorrhoid - Percentage of elective

and outpatient procedures performed in an outpatient setting - 2017/18

NHS Blackpool CCG


The national tariff for HRG FZ23A: Minor Anal Procedures, 19 years and over, is much higher for combined day case/ordinary elective spell procedures compared to outpatient

(£617 compared to £144). This reflects the fact that when performed in an inpatient theatre setting with a patient under general anaesthetic, procedures such as rubber band

ligation and injection of sclerosing substance into haemorrhoid have a much greater cost associated with them. Without knowing the cohort of patients being treated, it cannot

be said what an optimum percentage of procedures performed in an outpatient setting would be for a CCG, meaning this indicator has not been RAG rated and no opportunities

calculated. CCGs performing a low percentage of outpatient procedures, may however want to explore whether opportunities exist to perform more procedures in an outpatient

setting.

28.0

0.06.9

26.3 29.0

-

5

10

15

20

25

30

35

40

45

50

South Tees Sunderland Halton South Sefton St Helens North EastLincolnshire

South Tyneside Knowsley Stoke on Trent Blackpool Thanet

-

20

40

60

80

100

120


No Data No Data No Data No Data No Data No Data

England Best or Lowest 536.8 No benchmark calculated

3 Adms

(NSS)£3k (NSS)



Drainage of perianal abscess - Spend per 1,000 age-sex weighted population - 2017/18

224 164 168

219 229 249 261 270 341 374

412

-

100

200

300

400

500

600

North East Lincolnshire South Tees Sunderland Blackpool St Helens Knowsley Halton South Sefton Thanet Stoke on Trent South Tyneside

-

100

200

300

400

500

600

700



Outcomes



25 Lives

CCG under 75 mortality rates from liver disease should be considered alongside the liver disease pathway on a page. The 2017 Liver Disease Atlas of Variation also includes CCG

indicators on years of life lost from liver disease: https://fingertips.phe.org.uk/profile/atlas-of-variation.

274

Rate of mortality due to liver disease - directly standardised rate per 100,000

population - 2016

NHS Blackpool CCG

Source: NHS Digital - Primary Care Mortality Database (PCMD)

34

13 17 20 21 24 25 26 29 29

36

-

5

10

15

20

25

30

35

40

45

50


South Tees Sunderland Stoke on Trent South Tyneside St Helens Halton Knowsley Blackpool South Sefton

-

5

10

15

20

25

30

35

40

45

50



275

Annex

276

The following annex provides information on how indicator opportunities have been calculated, and high level metadata on data sources which have been used to produce pack indicators. Each of the sections included are listed in the contents below.

Please note that the criteria used to construct indicators, such as ICD10 and OPCS codes for SUS indicators, or individual chemicals for prescribing, are not included. These are available separately in the Excel data file for this pack, which can be requested from [email protected].

RightCare opportunity calculations………………………………………………..…..……................. p.277

SUS – high level metadata…….....…………….....………………………………..………..............… p.281

Prescribing – high level metadata………...……………………………………………......….............. p.291

Programme budgeting dataset – metadata and classifications……………….....................……… p.295

Further information on other data sources…………………………………………......….................. p.299

Referral to treatment times ……..………………………………………………………………………............... p.300

Diagnostic waiting times..………………………………………………………………………………….....…..... p.301

Annex introduction and contents


277

RightCare opportunity calculations

278

RightCare opportunities - overview

RightCare calculate opportunities to:

• show the scale of the issue;

• put data into a context that CCGs can relate to, i.e. their own population or budget; and

• help achieve clinical engagement.

The purpose of RightCare opportunities is to provide a scale of the difference between a CCG’s value for an

indicator compared to their similar 10 CCGs. They aim to start conversations and areas of investigation.

Further analysis will be required to establish any true potential saving or reduction in activity.

Opportunities are calculated to the best 5 for indicators with a clear ‘polarity’. This could be the highest 5 CCGs

in the similar 10, or the lowest 5. This gives a CCG a realistic ‘stretch target’ in cases where the direction they

need to move in (up or down) is clear.

In cases when indicators don’t have a clear ‘polarity’, opportunities may still be calculated to the highest or

lowest 5 CCGs. The benchmark represents the direction that it is expected CCGs will want to move towards.

For instance, opportunities are calculated to the lowest 5 for spend indicators without a clear ‘better’ direction.

Financial pressures often mean that CCGs are looking to save money; some CCGs may be achieving the

same or better care and outcomes for less spend.

There are instances within this pack where opportunities have been calculated to the similar 10 average.

These are likely activity indicators where it is not clear what ‘good’ looks like, however there is variation within

the measure at CCG level that could require investigation.

279

Example: Spend

Average value of lowest 5 CCGs in Similar 10

CCG value - £ rate

CCG opportunity =How many fewer £ from its current allocated budget / spend for that condition does the CCG need to spend in order to move down to the average spend rate of the lowest 5 in its peer group?

CCG value - %

Opportunity methodology

Average value of best 5CCGs in Similar 10 CCG opportunity =

How many additional people in its population does the CCG need to improve care for (for a specific indicator) in order to move to the average of the best 5 in its peer group?

Example: QOF

The potential opportunity highlights the scale of change that would be achieved if the CCG Value moved to the Benchmark Value. These can be calculated against the average of the lowest or highest five CCGs in a similar 10, or the similar 10 average.

280

Opportunity equations

In general, where a lower CCG value is considered ‘better’:

Potential Opportunity = (CCG value – Benchmark) * Denominator

The Denominator is:• the most suitable population data for the indicator e.g. CCG registered population, CCG weighted population, CCG patients

on disease register• scaled i.e. if the CCG value and Benchmark “per 1,000 population”, the denominator is expressed in thousands so 12,000

becomes 12

• divided by the number of years’ worth of data, to make opportunities per year (if needed)

Examples

Spend opportunity = (CCG value - Benchmark) * Denominator= (41,000 – 33,000) * 465,000 / 1,000= £3,720k

QoF opportunity = (Benchmark – CCG value) * Denominator(Higher is better) = (95% - 93%) * 120,000

= 2,400 patients

Procedure opportunities can be given in pounds or number of procedures (divide spend by unit cost).

Procedure (spend) opportunity = (CCG value - Benchmark) * Denominator= (2,500 - 1,500) * 420,000 / 1,000= £420k

Procedure (activity) opportunity = (CCG value - Benchmark) * Denominator / Unit Cost= (2,500 - 1,500) * (420,000 / 1,000) / (1,000,000 / 300)= 126 procedures

281

SUS

High level metadataThe following pages detail the high level metadata for indicators in this pack. For the full list of criteria used for each indicator (such as the ICD10 and OPCS codes), please see the metadata tabs in the Excel datafile for this pack which can be requested from [email protected]


282

SUS+ SEM code definitions

Note: Only patient classification codes 1 and 2 are included in inpatient indicators extracted from SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart).

Note: Only attendance status codes 5 and 6 are included in outpatient indicators extracted from SUS+ SEM (Secondary Uses Services Plus, Standard Extract Mart).

283

Dominant procedure definition

Information from NHS Digital on how the dominant procedure of the hospital spell is determined for HRG local payment groupers:

The patient record contains multiple procedures so the dominant procedure (procedure with highest hierarchy value) must be first determined. If a

single procedure is recorded for a patient and its hierarchy value is equal to or greater than 5, it will be used for grouping in the majority of

circumstances (see special cases related to outpatients).

Procedure Hierarchies provide a comparison mechanism which reflects the expected relative complexity of procedures across HRG chapters.

Each procedure has an associated value reflecting the expected relative resource use. Values 0 - 4 identify procedures which cannot be used for

grouping, other than in specific circumstances. Values 5 - 15 provide a scale of relative resource use where 5 represents the least and 15

represents the most resource-intensive procedures.

More detail can be found in the documents in the link below:https://digital.nhs.uk/services/national-casemix-office/downloads-groupers-and-tools/payment-hrg4-2017-18-local-payment-grouper

https://digital.nhs.uk/services/national-casemix-office/downloads-groupers-and-tools/payment-hrg4-2017-18-local-payment-grouper

284

Inpatient filters

• Spell_PBC is used to filter to spells with specific programme budgeting categories.

• Spell_Dominant_Procedure is used to filter to spells with specific dominant procedures. For some indicators Der_Procedure_All is used to filter

to spells with specific procedures anywhere in the spell.

• Spell_Primary_Diagnosis is used to filter to specific primary diagnoses. For some indicators Spell_Secondary_Diagnosis is used to filter to

spells with a specific secondary diagnoses or Der_Diagnosis_All is used to filter to spells with specific diagnoses anywhere in the spell.

• Combinations of Admission_Method and Patient_Classification are used to filter to spells with specific admission types:

Total indicators include all elective and non-elective admission method and patient classification combinations

• Cost_Type is used to filter to spells with a mandatory tariff.

Note:

• The data does not include CCGs which were not found in the official list of 195 CCGs across England

• Number of spells field counts all the patients admitted to hospital for a PBC/diagnosis/procedure and discharged in the financial year 2017/18.

Patients admitted in 2017/18 but not discharged until 2018/19 will not count in the indicators. Patients admitted in 2016/17 but not discharged

until 2017/18 will count in the indicators for 2017/18.

• The activity has been suppressed where it was less than or equal to 5 at CCG level or could reveal a figure less than or equal to 5 through

indicator interactions.

285

Inpatient standardised rate indicators

SUS+ SEM admitted patient care data is used, only patients with a mandatory tariff recorded have been selected.

The fields that were pulled from SUS SEM for inpatient standardised rate indicators include:

• CCG code (based on the GP practice code)

• Admissions is the count of spells

• Bed days is the sum of length of stay where spells with length of stay 0 have been recoded as a length of stay of 0.5

days in order to capture the impact of these admissions on total bed days for CCGs.

• Spend is the sum of Net_SLA_Payment (the cost before MFF is applied)

Age is grouped in the bands (0, 1-4, 5-9, ….., 90-94, 95+) for age/sex standardisation.

https://data.england.nhs.uk/ncdr/database/NHSE_SUSPlus_Live


286


The fields that were pulled from SUS SEM for inpatient percentage indicators include:

• CCG code (based on the GP practice code) – the data does not include CCGs which were not found in the official list of

195 CCGs across England




Inpatient percentage indicators


287

Inpatient average length of stay indicators


The fields that were pulled from SUS SEM for average length of stay indicators include:



• Sum of length of stay, where length of stay is number of times a patient is in a bed at midnight. Note this is different to the

bed days methodology, where patients with a 0 length of stay have been recoded as a length of stay of 0.5 days.

Spells whose length of stay was over 3 standard deviations above the national average were excluded, and a new national

average and CCG figures were calculated after this. This was done to avoid small numbers of admissions with extremely

long lengths of stay disproportionately skewing the average length of stay results.



288

Inpatient percentage readmission indicators


The parent admissions (i.e. initial admissions counted in the denominator) are joined to their child admissions (i.e. emergency readmissions within

30 days of discharge which could have occurred after the 2017/18 financial year) using the field Spell_RE30_Child_APCS_Ident from the parent

admission.

Spells which have a child admission which meets the criteria Spell_RE30_Indicator = 1 and Spell_RE30_Admit_Type = 0 and

Spell_RE30_Exclusion_Key is null are counted in the numerator. Field definitions can be found using this link:

https://data.england.nhs.uk/ncdr/database/NHSE_SUSPlus_Live/tbl_Data_SEM_APCS_1718_Der

Spells for maternity, childbirth, cancer, chemotherapy, radiotherapy, renal dialysis for acute kidney injury, and spells with self-discharge, patient

died, stillbirth, and not applicable parent discharge methods are excluded from the indicator to be consistent with the exclusions used for


https://data.england.nhs.uk/ncdr/database/NHSE_SUSPlus_Live/tbl_Data_SEM_APCS_1718_Der


289

Outpatient standardised rate indicators

SUS+ SEM outpatient attendance data is used, both tariff and non-tariff activity have been included.

The fields that were pulled from SUS SEM for outpatient standardised rate indicators include:


• Activity is the count of attendances

• Attend_Dominant_Procedure is used to filter to attendances with specific dominant procedures. (For some indicators

Der_Procedure_All is used to filter to attendances with specific procedures anywhere in the attendance)

• Treatment_Function_Code is used to filter to attendances with specific treatment function codes

Age is grouped in the bands (0, 1-4, 5-9, ….., 90-94, 95+) for age/sex standardisation.

Activity has been suppressed where it was less than or equal to 5 at CCG level or could reveal a figure less than or equal to

5 through indicator interactions.



290

Outpatient percentage indicators

SUS+ SEM outpatient attendance data is used, both tariff and non-tariff activity have been included.

The fields that were pulled from SUS SEM for outpatient percentage indicators include:


• Activity is the count of attendances


• Attend_Dominant_Procedure is used to filter to attendances with specific dominant procedures. (For some indicators

Der_Procedure_All is used to filter to attendances with specific procedures anywhere in the attendance)

• Treatment_Function_Code is used to filter to attendances with specific treatment function codes

Activity has been suppressed where it was less than or equal to 5 at CCG level or could reveal a figure less than or equal to 5

through indicator interactions.



291

Prescribing

High level metadataThe following pages detail the high level metadata for indicators in this pack. For the full list of chemicals and criteria used for each indicator, please see the metadata tabs in the Excel datafile for this pack which can be requested from [email protected]


292

Prescribing spend data: How is this derived?

This annex aims to explain the rationale around the prescribing information presented in this focus pack stating any

assumptions in the data and any caveats that need to be known to help the data to be interpreted.

NHS RightCare data uses programme budget categories (based on the World Health Organisation international

classifications of disease) as this supports a consistent nationally agreed approach to map spending across pathways of

care using multiple data sources. Some treatments and clinical pathways may appear across more than one programme

budget. The programme budget classifications are shown on the Programme Budgeting web page

https://www.england.nhs.uk/prog-budgeting/

Prescribing information presented by overall disease area (or programme budget main category) e.g. ‘Problems of the

gastrointestinal system’ and by specific condition (or programme budget sub-category) e.g. ‘Upper GI’ is derived by mapping

total spend by individual BNF chemical substances to each programme category. A document stating how BNF

chapters/subchapters are allocated to programme budget categories/sub-categories is provide on our website

https://www.england.nhs.uk/rightcare/products/nhs-rightcare-intelligence-tools-and-support/

Aggregating data to a programme budget category can encompass spend across a number of BNF sections and

subsections. For example overall ‘Gastrointestinal’ prescribing references all drugs form BNF Chapter 1: ‘Gastro-intestinal

system’ as well as certain drugs from Chapter 8: ‘Malignant disease and immunosuppression’ which map to the

‘Gastrointestinal’ programme budget category. Where a BNF chemical substance is identified as having more than one

indication an apportionment is applied to the total spend. For example spend on drugs under BNF 4.7.1 - ‘Non opioid

analgesics’ is apportioned as follows; 5% to Chronic Pain, 75% Musculoskeletal and 20% to Trauma and Injuries. These

apportionments have been agreed with clinical input. We are currently refreshing this mapping using a more detailed

approach utilising drug indication data.

https://www.england.nhs.uk/prog-budgeting/

https://www.england.nhs.uk/rightcare/products/nhs-rightcare-intelligence-tools-and-support/

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Prescribing spend data: Interpretation

The prescribing information shown in this focus pack is provided to enable CCGs to further understand the high level

prescribing indicators at both a programme and condition level shown in the NHS RightCare Where to Look packs.

This pack takes a more granular view of the prescribing data presenting a range of information using spend by BNF

chapters, sub-chapters and individual chemical substance compared to the similar 10 demographic peers.

The standard prescribing information is presented ‘per 1,000 population’ applying the ASTRO-PU age/sex weightings to the

CCG population. To maintain consistency across our products ASTRO-PU weightings have been used for most programme

level and BNF level indicators with STAR-PU populations being used where they are available and based on stakeholder

feedback.

Where appropriate a quantified opportunity or ‘difference’ in spend is shown for CCGs with a higher spend rate than the

lowest 5 of their similar 10 CCG peer group. This ‘difference’ is included to provide a real terms scale of difference between

the CCG and its peer group. The individual spend differences at a granular level should not be added together as the

lowest 5 CCGs may not be the same in every case.

As with all information in the RightCare packs it is important that the prescribing information is viewed in the

context of the whole pathway including disease prevalence, disease case finding, primary care management,

secondary care activity and outcomes.

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Prescribing spend: Metadata

*ASTRO-PU (Age, Sex and Temporary Resident Originated Prescribing Units) 5-year age and sex weightings have been applied to the CCG population to allow for better comparison of prescribing patterns. These weighted populations have been renormalised using the England population to give a CCG ASTRO-PU weighted population, which is on the same scale as the GP registered population. A CCG’s rate is then compared to the

similar CCG peers with similar demographics to calculate a potential opportunity.

ePACT.net

https://www.nhsbsa.nhs.uk/epact2

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Metadata and classifications

Programme Budgeting Dataset

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Overview of the NHS Programme Budgeting Expenditure Dataset

CCGs allocate the totality of the expenditure in their programme budgeting return. CCG spend is first allocated to a ‘care setting’, and then within each care setting it is further classified into one of 23 healthcare condition grouping (PBC main category) or their subcategories. Care settings are areas of healthcare services provided to a patient. Examples of care settings include primary care prescribing, elective admissions, outpatient attendances etc. The programme budgeting dataset included 13 care settings in 2017/18.

Within the programme budgeting benchmarking tool the care settings are classified as either ‘care settings recommended for benchmarking’ or ‘other care settings’. Care settings recommended for benchmarking are those in which we do not expect variation to be driven by differences in calculation methodologies. The ‘other care settings’ are defined as care settings in which variation may be driven by differences in data source or calculation methodology.

The aim of the dataset is to eventually provide health condition group level expenditure which can be used for benchmarking across the whole care pathway.

The aggregate expenditure on care settings recommended for benchmarking chart includes spend in the following care settings:

- Primary Care Prescribing - Non-elective admissions (in National Tariff Scope)- Critical Care - Elective admissions (in National Tariff Scope)- Drugs & devices - Outpatient Attendances (in National Tariff Scope)

- Outpatient Procedures (in National Tariff Scope)

The following care settings are not currently recommended for benchmarking and have been excluded from this pack:

- A&E - Other Inpatient (outside of National Tariff Scope)- Emergency Transport - Outpatient Activity (outside of National Tariff Scope)- Other Health Care Services - Other Inpatient (outside of National Tariff Scope)- Running Costs

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Spend in each care setting is allocated to a programme budgeting category using a specific mapping. A mapping is the assignment of a programme budgeting category to other classifications or definitions used within existing datasets.

For inpatient activity (including critical care), the mapping is based on the World Health Organisation International Classification of Diseases (ICD10), which has over 16,000 classifications. This is the same basis as programme level expenditure included in NCDR for inpatient activity.

ICD10 level classifications are currently only available for inpatient based care settings. Mappings for other care settings included within this pack are based on less granular classifications:

Outpatient attendances are mapped using Treatment Function Code (TFC);Outpatient procedures are mapped using Healthcare Resource Group (HRG); High cost drugs and devices are mapped using a specific drug or device based mapping;Primary care prescribing expenditure is mapped at the British National Formulary (BNF) chemical level.

In some cases it is not possible to directly allocate an existing classification to a programme budgeting category. In these circumstances the expenditure is either included within the ‘other’ programme budgeting category, or is apportioned using a proxy. An example of an apportionment basis is outpatient attendance activity under the ‘General Medicine’ TFC, in which the activity is apportioned using percentages derived from linkages with the inpatient dataset.

Programme budgeting mappings

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Programme budgeting expenditure dataset: Information on the calculation of indicators

Data are available for all 207 CCGS which existed in 2017/18. Figures have been aggregated for some organisations to create estimates which reflect the 2018/19 CCG structures.

The populations have been taken from or calculated using the 2017/18 overall weighted populations published in the CCG Allocations Workbook for 2016/17 to 2020/21.

Spend estimates and population adjustments have been used for the following CCGs:

NHS Manchester; NHS Bristol, North Somerset and South Gloucestershire;NHS Leeds;NHS Berkshire West;NHS East Berkshire;NHS Buckinghamshire;NHS Birmingham and Solihull;NHS North Cumbria [North Cumbria (01H) values represent 61.9% of the programme budgeting figures and populations for Cumbria CCG (01H) in 2017/18];NHS Morecambe Bay [Morecambe Bay (01K) values represent 100% of Lancashire North CCG (01K) figures plus 38.1% of the 2017/18 Cumbria CCG (01H) figures in 2017/18].

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Further information on other data sources

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Consultant-led Referral to Treatment Waiting Times

Consultant-led Referral to Treatment (RTT) Waiting Times is a monthly NHS collection. It records how long patients are waiting to start non-emergency consultant-led treatment. Data is provided for incomplete pathways (waiting times for patients waiting to start treatment at the end of each month), completed admitted pathways (waiting times for patients whose treatment started during the month) and completed non-admitted pathways (waiting times for patients whose wait for treatment ended during the month for reasons other than an inpatient or day case admission).

The incomplete waiting time standard was introduced in 2012. This states that the time waited must be 18 weeks or less for at least 92% of patients on incomplete pathways. There is no operational waiting times standard for completed pathways.

The charts contained within this pack highlight monthly changes in your CCG performance for patients waiting to start treatment by consultants specialising in Gynaecological or Urological conditions, with the 92% standard highlighted. It is advised that CCGs who are consistently falling below the standard review the reasons for this, and understand the factors which might be causing patients to be waiting more than 18 weeks. In addition, the average national performance against the standard has been included so CCGs can compare their performance against others.

More information about RTT waiting times can be found on the collection's web page: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/


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Diagnostic Waiting Times

These statistics measure waiting times for each of the key 15 diagnostic tests for patients still waiting for a test on the last day of each month and

the total number of tests carried out during each month. They have been published since January 2006 and are collected at an aggregate level from

providers of diagnostic tests for NHS patients. They provide high level performance information relating to each of the key 15 diagnostic tests

against the national standard; that less than 1% of patients should wait 6 weeks or longer for a diagnostic test. This standard forms part of both the

NHS Constitution and NHS England’s Everyone Counts: Planning for Patients 2013/14.

The data used in these statistics are collected on an aggregate form called DM01 via Unify2. Unify2 is NHS England’s standard online tool for the

collection and sharing of NHS performance data. Data is submitted against the commissioner responsible for the patient’s treatment. Once data is

submitted, it is checked and signed-off by commissioners. NHS England also performs central validation checks to ensure good data quality. Data

can then be aggregated by NHS provider or NHS Commissioner. Due to the data being collected in an aggregate format, it is not possible for further

breakdowns of the data to be obtained such as by age, sex, diagnosis etc.

Patients are included who are waiting for a diagnostic test/procedure funded by the NHS. This includes all referral routes (i.e. whether the patient

was referred by a GP or by a hospital-based clinician or other route) and also all settings (i.e. outpatient clinic, inpatient ward, x-ray department,

primary care one-stop centres etc.).

Patients are excluded if they are:

• waiting for a planned (or surveillance) diagnostic test/procedure and the patient is recorded on a planned waiting list, i.e. a procedure or series of procedures as part of a treatment plan which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency, e.g. 6-month check cystoscopy

• waiting for a procedure as part of a screening programme (e.g. routine repeat smear test or flexible sigmoidoscopy for the bowel scope screening programme). However, any subsequent diagnostic procedures that are triggered by an abnormal screening result should be included (e.g. Colonoscopy following positive screening for occult blood);

• an expectant mother booked for confinement;• currently admitted to a hospital bed and are waiting for an emergency or unscheduled diagnostic/test procedure as part of their inpatient

treatment.

The clock starts when the request for a diagnostic test or procedure is made (or for Choose and Book, when the patient has accepted an

appointment). The clock stops when the patient receives the diagnostic test/procedure.

More information on diagnostic waiting times can be found on the collection's web page: https://www.england.nhs.uk/statistics/statistical-work-

areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/


Documents

NHS RightCare Intelligence CCG Focus Pack