Public Health Report 2011-12 by NHS Herts Valleys CCG

Hertfordshire

Commissioning for better health in Hertfordshire

For further information, please call, write or email: Hertfordshire NHS Charter House Parkway Welwyn Garden City AL8 6JL Telephone: 01707 369688 Website: www.hertfordshire.nhs.uk Email: enquiries@hertfordshire.nhs.uk

Annual report of the Director of Public Health for Hertfordshire 2012 NHS Health Outcomes Framework indicators in Hertfordshire

Introduction

The structure of the Report • Introduction

• The NHS Outcomes Framework

• Using the NHS Outcomes Framework

• Domain 1 Preventing people from dying prematurely

• Domain 2 Enhancing quality of life for people with long-term conditions

• Domain 3 Helping people to recover from episodes of ill health or following injury

• Domain 4 Ensuring that people have a positive experience of care

• Domain 5 Treating and caring for people in a safe environment and protect them from avoidable harm

• Appendix

This document describes the health of the population of Hertfordshire according to the indicators of the NHS Outcomes Framework published in December 2011. For some indicators, the government has not yet finalised the technical detail, and for others, the format has been agreed, but the data are not yet published. We have presented proxy indicators to fill in some of these gaps. For some indicators the data are currently available at national level, but not yet at county or below so, for example, we have chosen to present life expectancy at 65 which is currently available at county level, rather than life expectancy at 75, which will become the standard. Data are not yet published for Clinical Commissioning Groups (CCGs), and so we have taken the old East and North Hertfordshire PCT and West Hertfordshire PCT groupings as the best currently available proxies1. Similarly, the next level of geography currently available is local authority district. Where the data are available, we have presented the trend over time for each indicator, and comparison to the regional or national average or the appropriate Office of National Statistics (ONS) cluster average. Comparison to the ONS cluster average (West Hertfordshire is in a group known as “Prospering Southern England” and East and North Hertfordshire is grouped with “New and Growing Towns”) has the advantage of comparing to populations of a similar socio-economic level. Some of the graphs display data points averaged over a few years. This has the advantage of allowing better representation of the underlying trend through smoothing, but the disadvantage of losing the detail of any particular year. Where the data are available below PCT level, we have presented a geographical breakdown by local authority district, or by practice. Practice-level data are shown in funnel plots which identify outliers, taking into account the greater statistical uncertainty with small numbers. Practices outside the outer ‘funnel’ are significantly different from the CCG average. It is generally clear whether a high value of an indicator is a better outcome e.g. life expectancy or worse e.g. mortality. It is worth pointing out that some indicators are composite indicators e.g. the survey questions on the management of long term conditions, cancer mortality, and ‘emergency admissions for acute conditions that should not usually require hospital admission’. While these indicators provide useful headlines for comparison, exploring the reasons for any unexpected findings will require the finer detail.

With the exception of Red House Practice and Royston the previous PCT boundaries are coterminous with the East and North Hertfordshire and Hertfordshire Valleys CCGs.

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The NHS Outcomes Framework 2011/12 1

Preventing people from dying prematurely

Overarching indicators 1a Mortality from causes considered amenable to healthcare (The Commissioning Board would be expected to focus on improving mortality in all the components of amenable mortality as well as the overall rate) 1b Life expectancy at 75

Improvement areas Reducing premature mortality from the major causes of death 1.1 Under 75 mortality rate from cardiovascular disease* 1.2 Under 75 mortality rate from respiratory disease* 1.3 Under 75 mortality rate from liver disease* 1.4 Cancer survival i One- and ii five-year survival from colorectal cancer iii One- and iv five-year survival from breast cancer v One- and vi five-year survival from lung cancer Reducing premature death in people with serious mental illness 1.5 An indicator needs to be developed* Reducing deaths in young children 1.6.i Infant mortality* 1.6.ii Perinatal mortality (including stillbirths)

Enhancing quality of life for people with long-term conditions

OOverarching indicator

2 Health-related quality of life for people with long-term conditions

Improvement areas Ensuring people feel supported to manage their condition 2.1 Proportion of people feeling supported to manage their condition Improving functional ability in people with long-term conditions 2.2 Employment of people with long-term conditions Reducing time spent in hospital by people with long-term conditions 2.3.i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) 2.3.ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Enhancing quality of life for carers 2.4 Health-related quality of life for carers Enhancing quality of life for people with mental illness 2.5 Employment of people with mental illness

*Shared responsibility with Public Health England *

Helping people to recover from episodes of ill health or following injury

Overarching indicators 3a Emergency admissions for acute conditions that should not usually require hospital admission 3b Emergency readmissions within 28 days of discharge from hospital

Improvement areas R

Improving outcomes from planned procedures 3.1 PROMs for elective procedures

Ensuring that people have a positive experience of care

Overarching indicators 4a Patient experience of primary care 4b Patient experience of hospital care

Improvement areas Improving people’s experience of outpatient care 4.1 Patient experience of outpatient services Improving hospitals’ responsiveness to personal needs 4.2 Responsiveness to in-patients’ personal needs

Preventing lower respiratory tract infections in children from becoming serious 3.2 Emergency admissions for children with LRTI

Improving people’s experience of accident and emergency services 4.3 Patient experience of A&E services

Improving recovery from injuries and trauma 3.3 An indicator needs to be developed.

Improving access to primary care services 4.4 Access to i GP services and ii dental services

Improving recovery from stroke 3.4 An indicator needs to be developed.

Improving women and their families’ experience of maternity services 4.5 Women’s experience of maternity services

Improving recovery from fragility fractures 3.5 The proportion of patients recovering to their previous levels of mobility / walking ability at i 30 and ii 120 days Helping older people to recover their independence after illness or injury 3.6 Proportion of older people (65 and over) who were still at home after 91 days following discharge from hospital into rehabilitation services

Treating and caring for people in a safe environment and protect them from avoidable harm

O Overarching indicators Three part measure patient safety measure consisting of: 5a patient safety incident reporting; 5b severity of harm; and 5c number of similar incidents.

Improvement areas

Improving the experience of care for people at the end of their lives 4.6 Survey of carers Improving experience of healthcare for people with mental illness 4.7 Patient experience of community mental health services Improving children’s experience of healthcare 4.8 An indicator needs developing, although this may be difficult to measure.

One framework defining how the NHS will be accountable for outcomes

Five domains articulating the responsibilities of the NHS

Ten overarching indicators covering the broad aims of each domain

Thirty one improvement areas

Reducing the incidence of avoidable harm 5.1 Incidence of hospital-related venous thromboembolism (VTE) 5.2 Incidence of healthcare associated infection i MRSA ii C Difficile 5.3 Incidence of newly-acquired category 3 and 4 pressure ulcers 5.4 Incidence of medication errors causing harm

looking in more detail at key areas within each domain

Improving the safety of maternity services 5.5 Admission of full-term babies to neonatal care

The NHS Outcomes Framework 2011/12 at a glance

Delivering safe care to children in acute settings 5.6 Incidence of harm to children due to ‘failure to monitor’

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Fifty one indicators in total measuring overarching and improvement area outcomes

Using the NHS Outcomes Framework

Preventing people from dying prematurely

While 60 indicators is a considerable number to examine and interpret, and increases further when examined over time and place, it is a small number with which to comprehensively describe the health of the local population.

This domain sets out to identify where improvements in healthcare can extend life, while recognising that healthcare is only one of the determinants of life expectancy and healthy life expectancy.

The indicators identify some areas where further investigation is warranted, where other sources of population-based data can be used in tandem to confirm or explain a finding, or where more detailed analysis better controlling for factors such as age, sex, deprivation etc. may explain unexpected results. Performance out of step with the average (in either direction) may be explained by inaccurate data, chance, or confounding (other factors such as differences in age or deprivation, for example). Just as an example, high breast cancer survival could reflect higher screening coverage and mask less effective treatment. Good patient-reported outcome measures (PROMs) taken at 3 months may not capture poor long term function.

The wider determinants include individualsâ&#x20AC;&#x2122; life style factors, the quality of social care; and external factors such as air quality, housing standards and fuel poverty. Dahlgren and Whitehead (1991) developed a model (pictured below) that showed how health is influenced, either positively or negatively, by a variety of factors. Since Hertfordshire is a relatively affluent part of the country, the population can be expected to enjoy better than average health. Even within Hertfordshire, the level of deprivation in each local authority district (measured by the Index of Multiple Deprivation 2010) is significantly lower than the national average, and lower than the regional average2. Figure 1.1 The wider determinants of health3

In addition, some important areas of health are not included within the NHS Outcomes Framework. Some are covered in the Public Health Outcomes Framework or the Adult Social Care Outcomes Framework, but by design, the outcomes frameworks are selective, high-level indicators providing guidance rather than a definitive comprehensive direction to action.

2 3

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www.apho.org.uk/default.aspx?RID=49802 Diagram adapted from Dahlgren and Whitehead (1991) Policies and strategies to promote social equity in health. Stockholm, Institute for Futures Studies. www.healthchallengevalleys.com/index.cfm?articleid=3407

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Indicators in this domain of the Outcomes Framework measure years of life lost attributable to causes ‘amenable’ to healthcare4, life expectancy, mortality from cardiovascular, respiratory and liver disease, cancer survival, excess mortality among mental illness, and stillborn, neonatal and infant deaths.

People who adopt the ‘four healthy behaviours’ - not smoking; taking exercise; moderate alcohol intake; and eating five servings of fruit and vegetables a day - live on average an additional fourteen years of life compared with people who smoke, do not exercise, have poor diets and drink alcohol excessively7.

Cause of death is not a good indicator of the burden of disease in a population unless a disease is fatal, but it can be a useful although blunt indicator of differences between populations, and show important trends over time in either underlying health or health care.

Continuing to promote these healthy behaviours (e.g. through Every Contact Counts) will be important in achieving improvements in this domain. Smoking-related deaths, for example, were significantly higher than the national average in Stevenage 2007-2009, and smoking prevalence is higher in Stevenage and Watford than both the regional and national average. High risk drinking, while not consistently worse than the national average, is worse than the regional average in each district of Hertfordshire. Healthy eating is considered generally better than in the East of England as a whole or nationally, except in Stevenage and Broxbourne, but levels of physical activity are thought to be low, with Stevenage and Hertsmere significantly worse than the national average; and levels of obesity reflect this pattern8.

Figure 1.2 shows a lower age-standardised mortality in females than males, and a general decline in mortality, especially from circulatory disease which comprises mainly coronary heart disease (mainly heart attack) and stroke. In 2006, mortality from circulatory disease fell below mortality from cancer for females. Figure 1.2 Falling mortality in the United Kingdom, 2000 and 2010 Males

Females

Summary • Life expectancy at age 65 is improving but there is a gap of 2 years between the districts with highest and lowest life expectancy, and larger gaps between the affluent and the deprived, which suggests that improvements can be made. • The geographical pattern of a number of diseases reflects known inequalities and emphasise the importance of reducing harm from tobacco and alcohol. • Cancer survival is similar to the regional average.

Circulatory disease accounts for 32% of all deaths (24% under 75). Cancer accounts for 29% (41% deaths under 75) and respiratory disease 14% (7% of those aged under 75)5. In the most recent health profile data, deaths before age 75 from cancer and circulatory diseases are not significantly higher than the national average in any local authority district6. There continue to be fairly steady decreases in mortality rates for these three broad disease groups. The reasons for this include improvements in the treatment of these conditions (improving survival), and initiatives over the last decade to improve people’s health through better diet and lifestyle (reducing incidence).

ONS consulted on a proposed list of causes considered amenable to healthcare in February 2011 and is currently undertaking work to update the list. This is expected to be complete by Spring 2012. ONS’s proposed amenable causes are listed in the consultation document here www.ons.gov.uk/ons/about-ons/consultations/closed-consultations/2011/definitions-of-avoidable-mortality/index.html 5 www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2010/stb-deaths-bycause-2010.html#tab-Key-findings 6 www.apho.org.uk/default.aspx?RID=49802

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www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050012 www.apho.org.uk/default.aspx?RID=49802

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1.1

1.2

Mortality from causes considered amenable to healthcare (indicator 1a)

Life expectancy at 75 years of age in i) males ii) females (indicator 1b)

This is a proxy indicator awaiting the national development of indicator measuring Potential years of life lost from causes considered amenable to healthcare, which will take into account the extent of premature deaths and will be more sensitive to the measurement of inequalities.

These indicators (one for males, one for females) will demonstrate success through improved diagnosis and treatment, in particular by improving early diagnosis of long term conditions; and investigation and treatment of patients presenting with acute symptoms e.g. of heart attack, stroke, hip fracture, pneumonia, or with cancer symptoms; and through healthy behaviours, particularly physical activity and smoking cessation, and for example, vaccination, high quality of social care, medication compliance.

Mortality from causes considered amenable to health care is an outcome which is associated with the quality of health care provided by the health system. It is based on the premise that deaths from certain causes within particular ages should not occur in the presence of timely and effective health care.

The data for this indicator are not yet published below national level but Life expectancy at 65 years of age is presented below as a proxy.

Figure 1.3 Directly standardised mortality rate for deaths considered to be amenable to health care, per 100,000 persons in Hertfordshire, 1993-2010, by CCG, males and females combined, 0+ years9

Figure 1.5 Male life expectancy at age 65 (years), 2004-2006 to 2008-2010, by CCG10

Figure 1.6 Female life expectancy at age 65 (years), 2004-2006 to 2008-2010, by CCG10

Figure 1.4 Directly standardised mortality rate for deaths considered to be amenable to health care, per 100,000 persons in Hertfordshire, 2007-2009, by local authority district, males and females combined, 0+ years9

â&#x20AC;˘ In the period 1993-2009, both regionally and locally, there has been a substantial reduction in rates of mortality from causes considered amenable to health care. â&#x20AC;˘ Within Hertfordshire, the most recent data show that the highest age-standardised mortality rates for deaths considered to be amenable to health are in Watford and Stevenage. 10 9

www.indicators.ic.nhs.uk

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Life expectancy at age 65 for males and females. Data are three-year rolling averages, based on deaths registered in calendar years and mid-year population estimates. Local authority districts according to East & North and Herts Valley CCGs. Source: Office for National Statistics.

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1.3 Under 75 mortality rate from cardiovascular disease (indicator 1.1) Figure 1.7 Life expectancy at age 65 (years), 2008-2010, by local authority district, for males (solid bars) and females (dotted bars)11

Circulatory disease accounts for 32% of all deaths (24% under 75)13 of which most are cardiovascular (predominantly coronary heart disease and stroke). Deaths under age 75 from cardiovascular disease (predominantly coronary heart disease and stroke) are more common in men than women. Both nationally and in Hertfordshire, there has been a rapid decline in the number of deaths under age 75 from cardiovascular diseases in the last decade, due in large part to reduced smoking prevalence.

However, cardiovascular disease (CVD) remains accountable for a large proportion of deaths and is more common in deprived and disadvantaged groups. In these populations particularly, improving cardiovascular mortality depends on: • reducing risk factors e.g. smoking, obesity, hypertension, cholesterol, poor diet, physical inactivity; • good access to effective and timely treatment for people with CVD e.g. anti-hypertensives, and access to surgery. As well as having a focus on cardiovascular disease prevention, the Heart and Stroke network is focusing on supporting the rapid access heart failure clinic, carrying out a review of community heart failure services, and further developing of cardiac rehabilitation services. Further details on the Heart and Stroke network can be found at www.bhhsnetwork.nhs.uk

• Life expectancy has increased nationally in the UK over the last 10 years. In the most recent data for the UK, a man aged 65 can expect to live another 17.8 years and a woman aged 65 another 20.4 years. The difference between male and female life expectancy in the UK at age 65 has decreased from 4 years in 1980-1982 to 2.6 years in 2008-2010.

Figure 1.8 Directly standardised mortality rate for deaths from cardiovascular disease, per 100,000 persons in Hertfordshire, 1993-2010, by CCG, males and females combined, 0+ years9

• Comparable data for Hertfordshire show improvements reflecting the regional and national picture. A man aged 65 in East and North Herts CCG can expect to live another 18.6 years and a woman aged 65 another 21.2 years. Life expectancy is slightly higher in Herts Valley with 18.9 years and 21.2 years for men and women, respectively. These are comparable to the East of England average of 18.7 years and 21.4 years for men and women, respectively. • It is important to remember that while life expectancy has increased, so has the number of years spent in ill health or with disability12. • Variations in life expectancy at age 65 remain across Hertfordshire, which suggests further improvements can be made. The gap between highest and lowest within Hertfordshire is 2.1 years for males and 2.3 for females. • Within Hertfordshire, the lowest life expectancy aged 65 is in Stevenage for males, but in North Hertfordshire for females.

11 12

www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-223356 www.ons.gov.uk/ons/rel/disability-and-health-measurement/health-expectancies-at-birth-and-age-65-in-the-unitedkingdom/2007-09/stb-he-2007-2009.html#tab-Trends-in-Disability-free-life-expectancy

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www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2010/stb-deathsby-cause-2010.html#tab-Key-findings www.indicators.ic.nhs.uk

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1.4 Under 75 mortality rate from respiratory disease (indicator 1.2) Figure 1.9 Directly standardised mortality rate from cardiovascular disease per 100,000 persons in Hertfordshire 2007-2009, <75 years, by local authority district, compared to the East of England (horizontal line)9

Respiratory disease includes asthma, chronic obstructive pulmonary disease, respiratory allergies, occupational lung disease and pulmonary hypertension. This indicator is not yet published below national level, and therefore a proxy indicator is presented below.

Chronic obstructive pulmonary disease (COPD) is one of the major respiratory diseases. In Hertfordshire there were on average 104 deaths per year from COPD in individuals under 75 years of age over the period 2007-2009, and more than 2000 Hertfordshire residents currently live with COPD. Figure 1.10 Directly standardised mortality rate for deaths from chronic obstructive pulmonary disease (COPD), per 100,000 persons in Hertfordshire, 1993-2010, by CCG, males and females combined, 0+ years14

• Rates for under 75 mortality from cardiovascular disease have fallen considerably and the downward trend appears set to continue. • The rates in West Hertfordshire and in East and North Hertfordshire are similar to the East of England. • Variation among localities broadly reflects known patterns of deprivation.

www.indicators.ic.nhs.uk

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Deaths from bronchitis, emphysema and other COPD, per European standard 100,000 population. Local authority districts grouped according to East & North and Herts Valley CCGs. www.indicators.ic.nhs.uk

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1.5 Under 75 mortality rate from liver disease (indicator 1.3) Figure 1.11 Directly standardised mortality rate from chronic obstructive pulmonary disease (COPD), per 100,000 persons in Hertfordshire, 2007-2009, by local authority district, males and females combined, <75 years, compared to the East of England average (horizontal line)14

This indicator is not yet published below national level but a narrower definition, ‘Data on under 75 year mortality from chronic liver disease including cirrhosis’ is published. Improvements in this indicator can be achieved by:

• prevention e.g. reduction in alcohol consumption, promotion of healthy eating; • early detection and management of risk factors including hepatitis B, hepatitis C; • high quality treatment e.g. high quality social care in hospital at home, medical compliance. Figure 1.12 Directly standardised mortality rate for deaths from chronic liver disease including cirrhosis, per 100,000 persons in Hertfordshire, 1993-2010, by CCG, males and females combined, 0+ years15

• The directly standardised mortality rate in people under 75 from COPD in Hertfordshire is consistent with the East of England average. However, this county average masks a range within Hertfordshire from 5.9 to 14.9 per 100 000 population. Around 50% of COPD is caused by smoking, reflecting potentially preventable deaths. • Local initiatives to reduce ill-health and deaths from COPD focus on smoking cessation, on improving case finding, and early diagnosis and management of COPD in primary care. • Further information on mortality from key components of respiratory disease can be found here: www.indicators.ic.nhs.uk

Deaths from bronchitis, emphysema and other COPD, per European standard 100,000 population. Local authority districts grouped according to East & North and Herts Valley CCGs. www.indicators.ic.nhs.uk

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Deaths from liver disease, per European standard 100,000 population. Local authority districts grouped according to East & North and Herts Valley CCGs. www.indicators.ic.nhs.uk/download/NCHOD/Data/25A_043DR0074_09_V1_D.xls

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1.6 Cancer survival (indicators 1.4i-vi) Figure 1.13 Directly standardised mortality rate from chronic liver disease per 100 000 persons in Hertfordshire, 2007-2009, by local authority district, males and females combined, <75 years, compared to the East of England average (horizontal line)15

About one in three people will develop cancer at some point in their life and one in four people die from cancer. Higher cancer mortality may reflect either higher incidence or lower survival after diagnosis. A higher incidence usually reflects a higher prevalence of risk factors for cancer development e.g. smoking, physical inactivity and poor diet. Poor survival additionally reflects poor uptake of screening, delay in initial presentation, and the quality of cancer services e.g. delay in diagnosis, delay in time to definitive treatment, inappropriate treatment or poor after-care.

Since people living in Hertfordshire are generally more affluent and healthier than the national average, cancer incidence should be lower and cancer survival higher. Diagnosis at an earlier stage, improved access to treatment and tackling risk factors relevant to social inequalities such as obesity and smoking would all improve survival rates. Comparative reports (by PCT and by GP practice) of elements of the health service for cancer are available here: www.cancertoolkit.co.uk For example, in the most recent data GP referrals for suspected cancer in Hertfordshire were among the lowest in England16. However, this may be explained, at least in part, by a lower underlying incidence, and more private referrals compared with England as a whole. A campaign to encourage earlier presentation with lung cancer in primary care ran in Hertfordshire in Spring 2011. Details of this and the rest of the work of the Mount Vernon Cancer Network can be found here: www.mountvernoncancernetwork.nhs.uk/hcp â&#x20AC;˘ Increasing mortality from chronic liver disease between 1993 and 2005 appears to have slowed, but there remains an increasing trend. â&#x20AC;˘ Variation among the districts of Hertfordshire could be due to chance but there appears to be greater variation in East and North Hertfordshire.

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The Department of Health published the Cancer Intelligence Framework in December 2011, to support improvements to the collection of cancer information. www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131696

www.rightcare.nhs.uk

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1.6.1

1.6.2

One and five year relative survival from colorectal cancer

One and five year relative survival from breast cancer

Figure 1.14 Survival following diagnosis of colorectal cancer: one year age standardised relative survival rate (%), 3-year average, 1985-2004, by Hertfordshire and East of England, 15-99 years17

Figure 1.16 Survival following diagnosis of breast cancer: one year age standardised relative survival rate (%), 3-year average, 1985-2008, by Hertfordshire and East of England, 15-99 years17

Figure 1.15 Survival following diagnosis of colorectal cancer: five year age standardised relative survival rate (%), 3-year average, 1985-2004, by Hertfordshire and East of England, 15-99 years17

Figure 1.17 Survival following diagnosis of breast cancer: five year age standardised relative survival rate (%), 3-year average, 1985-2004, by Hertfordshire and East of England, 15-99 years17

• Survival at one year after diagnosis with colorectal cancer has been consistently above the national average. • National improvement in survival at five years after diagnosis with colorectal cancer has not been seen in Hertfordshire. 17

• A similar proportion of women survive at one year (around 96%) and five years (around 84%) after a diagnosis of breast cancer in both Hertfordshire and the East of England. • The trend shows continuing improvement over time in survival following diagnosis of breast cancer at 1 and 5 years.

Data available from the Mount Vernon Cancer Network. The graphs present data averaged over years as a standard to better display underlying trend.

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1.6.3

1.7

One and five year survival rate from lung cancer

Under 75 mortality rate from cancer (indicator 1.4vii)

Figure 1.18 Survival following diagnosis of lung cancer: one year age standardised relative survival rate (%), 1985-2009, for Mount Vernon Cancer Network and England, 15-99 years17

Figure 1.20 Directly standardised mortality rate for deaths from cancer, per 100,000 persons in Hertfordshire, 1993-2010, by CCG, males and females combined, 0+ years9

Figure 1.19 Survival following diagnosis of lung cancer: five year age standardised relative survival rate (%), 3-year average, 1985-2004, by Hertfordshire and East of England, 15-99 years17

• The poor prognosis of lung cancer is reflected in the survival figures for both Hertfordshire and East of England. • Note that one year survival from lung cancer in the Mount Vernon Cancer Network improved from 24% to 32% between 2006 and 200917 and in the most recent data is similar to the regional and national average.

Figure 1.21 Directly standardised mortality rate from cancer per 100,000 persons in Hertfordshire, 2007-2009, by local authority district, males and females combined, <75 years, compared to the East of England average (horizontal line)9

• While all-cancer mortality reflects a combination of incidence and survival, and may disguise differences among localities for different cancers, it can be can be a useful measure to highlight differences among areas. • The pattern among the Hertfordshire districts reflects known variation in smoking and arealevel deprivation.

• Since 2000, survival with lung cancer at five years in Hertfordshire has been similar to the regional average. 17

Data available from the Mount Vernon Cancer Network. The graphs present data averaged over years as a standard to better display underlying trend.

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www.indicators.ic.nhs.uk

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1.8 Excess under 75 mortality in adults with serious mental illness (indicator 1.5) This indicator has not yet been finalised and data are not available.

1.9 Infant mortality (indicator 1.6 (i))

Enhancing quality of life for people with long-term conditions This domain focuses on improving the quality of life for those affected by long-term conditions.

• Infant mortality is expressed as the number of deaths at ages under one year per 1,000 live births. It is a measure of the well-being of infants and pregnant women and is associated with a variety of factors such as maternal health, socioeconomic conditions, and the quality of and access to medical care.

There is one overarching indicator and six sub-indicators which are based on results from the following data sources:

• Infant mortality has been broadly falling, nationally and locally.

• GP Patient Survey

• Reductions in infant mortality are associated with reductions in the prevalence of obesity and smoking, improving parental confidence and education, and reducing child poverty, including overcrowding.

• Labour Force Survey

Figure 1.22 Infant mortality per 1000 live births, 1997-2009, by East and North Herts, West Herts and East of England18

• Hospital Episode Statistics (NHS Information Centre) • Population Statistics (Office for National Statistics). This domain is still under development to try to capture the NHS contribution to the prevention of long term conditions, decide how to best adjust for casemix, and how to target surveys appropriately to people with different conditions. The available data show that Hertfordshire residents are less likely to report living with a long term condition than the national average, but feel less supported than the national average in managing their conditions. Although there are few statistical outliers, there is wide variation in the proportion of people feeling supported to manage among practices within Hertfordshire. Recent local activities to improve the support for those with long-term conditions have included: • interventions such as screening programmes, along with early identification and management of risk factors to mitigate the development of chronic illnesses • using information from patient surveys and trackers, audits and complaints to identify and support teams to improve their services • working with transport providers to support and influence improvements in access to hospital services

• Infant mortality in Hertfordshire is generally below the regional average.

• developing cardiac services, including expanding cardiac catheterisation capacity to increase timely access to cardiac treatment

• Since there are few deaths in any single year, the observed rate may fluctuate considerably from year to year although the underlying risk has not changed.

• multiagency working to support improved outcomes following stroke • joint working to redesign and improve care pathways for people with long term conditions such as diabetes (via the Single Unified Diabetes Scheme) and rheumatology (via extension to the community-based musculoskeletal (MSK) triage service; COPD and oxygen services; introduction of early diagnosis dementia clinics.

1.10 Neonatal mortality and still births (indicator 1.6ii) This will measure the number of neonatal deaths19 and stillbirths20 as a proportion of the number of live births and still births. This indicator is not currently available below national level.

While some work has been done to increase patient and staff education e.g. the provision of patient diabetes education (DESMOND), the data suggest that more could be done to increase patient and carer empowerment. Patient held care plans are one route under discussion.

Neonatal mortality data alone are available at county and local authority level but small numbers (fewer than 5 annual deaths per local authority district) hamper comparisons over time and geography.

www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2010/stb-deathsby-cause-2010.html Death 0-27 days of a live birth 20 Deaths in babies born after 24 completed weeks of gestation who did not at any time breathe or show signs of life. 19

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2.1 Health-related quality of life for people with long-term conditions (indicator 2) Interpretation of (and isolating necessary action on) the survey results is complicated by the grouping of multiple conditions together, by the subjective nature of questions (which may change over time) and the poor response rate. For example, in the GP patient survey in July to September 2011 in Hertfordshire, 8621 questionnaires were returned out of a total of 21121 distributed (41% response rate). This is marginally better than the response rate for England (38%) but responders are likely not to be fully representative of their group. The re-admission data included in this domain indicate that Hertfordshire is doing well in keeping emergency admissions for ambulatory care sensitive conditions low. In young people, emergency admissions for asthma, diabetes and epilepsy are below the regional average.

Data for the overarching indicator are not yet published but the intention is to use data from the GP Patient Survey to describe health-related quality of life for people with long term conditions, controlling for measurable confounders such as age, gender, casemix etc.21 For the present time, the following charts describe the proportion of the population of Hertfordshire with at least one long term condition, and their health status.

Figure 2.1 Responses to the question ‘Do you have a long-standing health condition?’, July to September 201122

Summary • The available survey data indicate Hertfordshire patients feel less supported to manage their long term health conditions than the national average, and there is wide variation among practices. • The final indicator will be adjusted for case-mix (method to be confirmed). This may reduce the observed current variation among practices and facilitate the identification of outliers. • More detailed information is needed to pinpoint the gaps in provision of support that may remain after the current efforts to better support patients in self-management can be expected to have had effect. • Readmission data for ambulatory sensitive care conditions and unplanned admission admissions in children look favourably low in Hertfordshire.

• There are fewer people living with long-standing health conditions in Hertfordshire than in England as a whole. • According to the Health Survey for England, the prevalence of long-standing health conditions in England was broadly stable, ranging from 42% to 45% from 2003-201023.

The GP Patient Survey (GPPS) questionnaire in 2011-2012 includes questions on respondents’ health status using the five dimensions of the EuroQuol (EQ-5D) survey instrument: Mobility, Self-care, Usual Activities, Pain/Discomfort, Anxiety/Depression www.euroqol.org PCT-level GP Patient Survey 2011-2012 data are available for July-September 2011 and practice-level data are due to be published in June 2012. 22 GP Patient Survey. Individuals asked to indicate whether any of the following applied to them: Alzheimer’s disease or dementia, Angina or long-term heart problem, Arthritis or long-term joint problem, Asthma or long-term chest problem, Blindness or severe visual impairment, Cancer in the last 5 years, Deafness or severe hearing impairment, Diabetes, Epilepsy, High blood pressure, Kidney or liver disease, Learning difficulty, Long-term back problem, Long-term mental health problem, Long-term neurological problem, Another long-term condition, None of these conditions, I would prefer not to say. www.gp-patient.co.uk/results/ (Hertfordshire, n=10,937, England, n=517,924) 23 Health Survey for England. Individuals asked to self-report on their health as either very good/good health, very bad/bad health, having at least one long-standing illness or acute sickness. www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/health-survey-for-england

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2.2 Proportion of people feeling supported to manage their condition (indicator 2.1) Figure 2.2 Health status of respondents across five different areas, July-September 201124

The GP Patient Survey asked patients who had previously reported having a long-standing health condition, whether they felt supported in managing their condition. Individuals were asked to consider all services and organisations, not just health services.

Figure 2.3 The extent to which people feel supported managing their long-term health conditions, July-September 201125

• Across all five dimensions of health status, fewer Hertfordshire respondents report a problem than nationally. • Respondents reporting a health problem were more likely report pain and discomfort and anxiety and depression than problems with mobility, self-care or restrictions on usual activities. Figure 2.4 People who feel supported managing their long-term health conditions by practice in East and North Hertfordshire CCG, March 2010-April 201126

GP Patient Survey. All individuals asked to comment on their health status, not purely those who had acknowledged having a longstanding health condition. www.gp-patient.co.uk/results/ (Hertfordshire, n= ≈ 10,810, England, n ≈ 509,913)

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GP Patient Survey. Only those individuals reporting a long-standing health condition included. www.gp-patient.co.uk/results. (Hertfordshire, n= 4,842, England, n=240,669) 26 GP Patient Survey. Annual summary data from March 2010-April 2011. Plot represents a total of those patients who responded to the question ‘In the last 6 months, have you had enough support from local services or organisations to help you manage your long-term condition’ with either yes, definitely or yes, to some extent. www.gp-patient.co.uk/results/archive_weighted/practicereport/

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2.4 Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) (indicator 2.3.i) Figure 2.5 People who feel supported managing their long-term health conditions by practice in Hertfordshire Valleys CCG, March 2010-April 201127

Ambulatory care sensitive conditions (ACSC) are a group of 19 chronic or acute diseases for which hospital admission in adults may be avoided by effective management in primary care (Appendix). These fall into three groups - those preventable by vaccination; those avoidable through secondary prevention or better patient self management; and those amenable to lifestyle interventions.

It is important to reduce serious deterioration in people with chronic ambulatory care sensitive conditions, to prevent emergency hospital admissions of these conditions which may otherwise be managed in primary care. Optimal use of referral pathways and providing sufficient support after primary treatment (secondary prevention), may better enable people to self-manage their condition. Figure 2.6 Standardised rate of hospital admissions for people with ambulatory care sensitive conditions per 100,000 for 2008-2009, by CCG, compared to the relevant ONS cluster average28

• Fewer people in Hertfordshire report feeling supported to manage their long-term health condition compared with the national average. • Comparing previous GP Patient Survey data from financial year April 2009 to March 2010 and April 2010 to March 2011, the proportion of people who felt supported (combination of definitely and to some extent) fell from 56% to 50% in Hertfordshire. The proportion of people who did not feel supported rose from 13% to 14% and the proportion of people who didn’t need support rose from 29% to 31%. • The proportion of patients feeling supported is similar across the CCGs, but there is a wide (although the differences are often not statistically significantly different) among practices within CCGs.

2.3

• The rate of emergency admission for ambulatory sensitive care conditions is lower in both East and North Hertfordshire and West Hertfordshire than regionally or nationally, and than their respective cluster averages (New and Growing Towns, Prospering Southern England

Employment of people with long-term conditions (indicator 2.2)

• There has been little change over period for which data available.

This indicator will measure changes in the percentage of people with a long-term health condition who are classed as employed using the International Labour Organisation definition of employment. This, compared to the percentage of all respondents classed as employed, acts as a proxy measure of how well disease progression is being mitigated and conditions are being managed to facilitate realisation of employment aspirations for these patients. Data are not currently published at county level.

GP Patient Survey. Annual summary data from March 2010-April 2011. Plot represents a total of those patients who responded to the question ‘In the last 6 months, have you had enough support from local services or organisations to help you manage your long-term condition’ with either yes, definitely or yes, to some extent. www.gp-patient.co.uk/results/archive_weighted/practicereport/

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www.ic.nhs.uk/services/nhs-comparators

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2.5 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s (indicator 2.3.ii)

Figure 2.9 The rate of emergency admissions for epilepsy per 100,000 population in people under 19 years old, by year from 2003-201029

Some specific long-term conditions, such as asthma, diabetes and epilepsy, can be managed largely in primary care. Reducing the number of emergency admissions for these conditions will help reduce the unplanned time spent in hospital by children.

Early identification of these conditions is important, as well as ensuring that interventions which may prevent admissions, such as vaccinations, are delivered to all patients at risk. The Child and Maternal Health Observatory report the number of emergency admissions for asthma, diabetes and epilepsy in people under 19 years old. Figure 2.7 The rate of emergency admissions for asthma per 100,000 population in people under 19 years old, by year from 2003-201029

• In people under 19, emergency admissions are higher for asthma, than for either diabetes or epilepsy in both East and North Hertfordshire and West Hertfordshire. • Emergency admissions for asthma appear to be stable. • Emergency admissions for diabetes appear to be increasing. • Emergency admissions for epilepsy appear to be increasing regionally and in East and North Hertfordshire.

Figure 2.8 The rate of emergency admissions for diabetes per 100,000 population in people under 19 years old, by year from 2003-201029

Child and Maternal Health Observatory. atlas.chimat.org.uk/IAS/dataviews/listbytheme

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2.6

2.7

Health-related quality of life for carers (indicator 2.4)

Employment of people with mental illness (indicator 2.5)

This is a new indicator whereby the importance of the health and wellbeing of carers are being recognised. A question will be included in the GP Patient Survey 2011-2012 for those individuals who are carers to assess their health status across the five different areas of mobility, self-care, usual activities, pain/discomfort and anxiety/depression.

Employment is an important way of gaining improved functional ability in patients with a mental illness.

Following the Prevention and Wellbeing review earlier this year, Hertfordshire County Council and NHS Hertfordshire pooled a budget to fund services which promote physical and mental wellbeing, reduce preventable ill health and disability and to support and sustain carers30. The Joint Carers Plan has funded initiatives to meet the following eight key outcomes, which carers should be able to do:

Respondents to the Labour Force Survey, who reported they were employed, were asked whether they had depression, bad nerves or anxiety, severe or specific learning difficulties, mental illness, or suffer from phobia, panics or other nervous disorders.

Determining the percentage of respondents who have a mental illness who are classed as employed, compared to the percentage of all respondents classed as employed, can be used to measure the quality of care for these conditions. Data are not yet published nationally at the county level but proxy local data have started to be collected.

• carry on caring if they want to; • work if they want to; • have a life outside caring; • stay fit and healthy, and be safe; • access full benefit entitlements; • get good quality information when needed; • feel respected as carers, as partners in care; • (where carers are children/young people) not have to take on inappropriate levels of caring because of the disability of parents/family. Examples of services currently funded by Hertfordshire PCT include31: • flexible and short breaks for carers (Hertfordshire Crossroads North and South, Turning Point Services Ltd); • emotional support (Hertfordshire Society for the Blind, Watford African Caribbean Association); • day activities (Guidepost Trust, Hailey Day Centre); • funding support (Carers in Herts). It is expected that the final indicator will be published in 2012 and updated bi-annually.

Hertfordshire County Council and NHS Hertfordshire Joint Carers Plan. www.hertsdirect.org/services/advben/carersupport/carersplan/ A full list of services available in the Hertfordshire PCT Carers Budget 2011-2012. www.hertsdirect.org/docs/xls/p/pctcarers.xls

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Helping people to recover from episodes of ill health or following injury Improvements in this domain are shown by reducing the number of cases in which recovery is interrupted by emergency admissions, and measuring positive progress in recovery following ill-health or injury. It comprises indicators both of adverse outcomes (e.g. emergency admissions) and of the effectiveness of care (e.g. patient-reported outcome measures (PROMs). The overarching indicators of emergency (re)admissions set out to measure the effectiveness of the care system in contrast with those in Domain 5 which are designed reflect adverse outcomes attributable to the care itself e.g. early readmission may reflect level of available social care provision.

3.1 Emergency admissions for acute conditions that should not usually require hospital admission (Indicator 3a) • The rates of emergency hospital admissions for acute conditions usually managed in primary care in Hertfordshire have been rising since 2004-2005. • Since 2006-2007 the rates in Hertfordshire have been lower than the ONS Prospering Southern England cluster average, which provides a benchmark based on a cluster of areas with similar population characteristics

• The latest available rates of admission for these conditions show that in 2008-2009, within the East and North Hertfordshire CCG area, the rate was highest in Stevenage and lowest in Broxbourne; in the Herts Valley CCG area the rate was highest in Watford and lowest in Hertsmere. • The prevalence of long-term conditions in the population and external non-health service factors such as fuel poverty may contribute to higher rates of emergency hospital admissions for these conditions. Figure 3.1 Emergency hospital admissions for acute conditions usually managed in primary care, per 100,000 persons, in Hertfordshire, 2002-2003 to 2008-2009, by previous PCT boundaries, males and females of all ages combined33

The PROMs data will be expanded, and indicators to measure recovery after trauma and after stroke are being developed. As part of the development of the Outcomes Framework, a list of acute conditions that do not usually require hospital admission has been derived (e.g. ear, nose and throat infections, kidney and urinary tract infections and heart failure)32. Summary • Emergency hospital admissions for acute conditions usually managed in primary care are lower in Hertfordshire than in the comparable ONS cluster but variations remain within Hertfordshire, which suggests that more can be done. • The most recent published re-admission data show a fall in West Hertfordshire but a rise in East and North Hertfordshire, and merit further examination by the acute trust. • There is less patient-reported health gain after knee replacement than the England average. • Emergency admissions for children for lower respiratory tract infections have been consistently lower in Hertfordshire than the ONS cluster average since 2002-2003, but variation within Hertfordshire suggests more could be done. • The proportion of older people still at home 91 days after discharge to rehabilitation is similar to the national average.

Full list of conditions is given in the Technical Appendix to the NHS Outcomes Framework www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131721.pdf

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Data are currently available for a proxy but very similar indicator. www.indicators.ic.nhs.uk

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Figure 3.2 Emergency hospital admissions for acute conditions usually managed in primary care in Hertfordshire, per 100,000 persons, 2008-2009, by local authority district, males and females of all ages combined33

Figure 3.4 Emergency hospital admissions for acute conditions usually managed in primary care, per 100,000 persons, in the Herts Valley and Red House CCGs, 2010-2011, by general practice, males and females of all ages combined34

Figure 3.3 Emergency hospital admissions for acute conditions usually managed in primary care, per 100,000 persons, in the East and North Hertfordshire CCG, 2010-2011, by general practice, males and females of all ages combined34

Data are currently available for a proxy but very similar indicator. www.indicators.ic.nhs.uk 34 NHS Hertfordshire Secondary Uses Service

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NHS Hertfordshire Secondary Uses Service

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3.2 Emergency re-admissions within 30 days of discharge from hospital (Indicator 3b) • Lower rates of emergency readmissions within 30 days of discharge from hospital may indicate effective recovery from illness and injuries that required hospitalisation; it is important that hospitals provide high quality care and discharge patients only when it is clinically appropriate to do so.

Figure 3.6 Directly standardised rates of 30-day emergency readmissions by GP practice in East and North Clinical Commissioning Group, 2010-2011, males and females of all ages combined34

• Since 2005-2006, the rate of emergency readmissions within 30 days of discharge has remained stable for West Hertfordshire Hospitals NHS Trust. However, in the East and North Hertfordshire NHS Trust the rate has risen from 6.4% in 2005-2006 to 8.3% in 2009-2010. • The most recent data (2010-2011) show similar averages for the East and North CCG and the Herts Valleys and Red House CCGs, but wide variation within each of the CCGs, and some practices with a significantly higher rate. • Non-health service factors such as deprivation, the prevalence of long-term conditions, and fuel poverty in the population may contribute to the observed trends; however, more work may be required in discharge planning. • An audit of a sample of re-admissions is underway, to identify clinical and social factors across the pathway that could be addressed to reduce re-admissions. Following a pilot and an evaluation of the next steps, the findings will be rolled out more generally as appropriate. Figure 3.5 Emergency re-admissions within 28 days of discharge from hospital, percent of total spells, in Hertfordshire, 2006-2007 to 2009-2010, by CCG, males and females 16+35

Figure 3.7 Directly standardised rates of 30-day emergency readmissions by GP practice in Herts Valleys and Red House Clinical Commissioning Groups, 2010-2011, males and females of all ages combined34

The definition is based on all emergency re-admissions within 28 days for all diagnoses. The 2012/13 NHS Outcomes Framework definition for this indicator excludes cancer and obstetric admissions. www.indicators.ic.nhs.uk

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NHS Hertfordshire Secondary Uses Service

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3.3

3.4

Patient Reported Outcome Measures for elective procedures (Indicator 3.1)

Emergency admissions for children with lower respiratory tract infections (Indicator 3.2)

• Patient Reported Outcome Measures (PROMS) measure health-related quality of life from the patient perspective and cover four elective (non-urgent) procedures: groin hernia surgery, hip replacement, knee replacement and varicose vein surgery. The health gain after surgery is calculated using pre- and post-operative surveys.

• Improvements in this indicator measure the prevention of complications in vulnerable children and improvements in the management of these conditions in the community.

• The greatest health gain among the four conditions is from hip replacement. • More conditions are due to be reported through PROMs. • Health gains in Hertfordshire are similar to the England average. • In 2011 NHS Hertfordshire introduced a “Stop before the op” policy for routine hip and knee surgery. The policy aims to improve outcomes from these routine operations by encouraging people who smoke to give up and by encouraging overweight people to lose weight before surgery. In 2012 the policy has been extended to most elective surgery.

• Since 2003-2004 the rate of emergency admissions for children with lower respiratory tract infections in Hertfordshire has been lower than the ONS cluster average.

• Variations in the rate of emergency admissions may be affected by levels of deprivation, co-existing health problems in the population, and parental confidence in managing their ill children at home. Figure 3.9 Emergency admissions for children (less than 16 years) with lower respiratory tract infections in Hertfordshire, per 100,000 persons, 2002-2003 to 2009-2010, males and females combined9

Figure 3.8 Case mix adjusted EQ-5D average health gain following four elective procedures, April 2009 to February 2011, by hospital trust, males and females combined, 12 years and over36

Figure 3.10 Emergency admissions for children (less than 16 years) with lower respiratory tract infections in Hertfordshire, per 100,000 persons, 2009-2010, by local authority district, males and females combined9

EQ-5D (trademark EuroQol Group) is a standardised quality of life questionnaire with questions spanning five domains: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The overall score is reported on a scale of 0 to 1, with a higher score equivalent to higher perceived quality of life. This chart displays average casemix adjusted health gain, which is the average difference between pre- and post-operative EQ-5D score, adjusted for demographic differences between populations. Capped lines represent 99.8% confidence intervals. Varicose vein data are not presented for East and North Hertfordshire Trust due the low number of questionnaires completed. EQ-5D is trademark of the EuroQol Group. www.hesonline.nhs.uk

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www.indicators.ic.nhs.uk

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3.5 The proportion of older people who were still at home 91 days after discharge from hospital into rehabilitation services (Indicator 3.6.i) • The aim of measuring this outcome is to ensure that older people are helped to recover their independence after illness or injury through good quality rehabilitation services.

Figure 3.11 The proportion of older people (65 years and over) who were still at home 91 days after discharge from hospital into rehabilitation services in Hertfordshire41

• The proportion of older people still at home 91 days after discharge from hospital into rehabilitation services may also be affected by levels of deprivation and co-existing health problems in the population. • The Hertfordshire CCGs, PCT, county council, hospital and community trusts have all signed up to the Intermediate Care Strategy, which aims to improve health and social care community services by focusing on transforming three main areas: access and assessment; buying bed-based services; and community teams. • An early pilot in the Welwyn-Hatfield locality will test the feasibility of joined-up access points into Hertfordshire Community Trust’s community nursing and therapy and enablement services. The new services will accept referrals from GPs and other health professionals. • The programme has also begun a process of public engagement on decommissioning ‘bedbased’ intermediate care services from some of the older community hospitals in favour of care services at home or in care homes close to home. Windmill Community Hospital was closed in September 2011 and replacement services commissioned from the nearby Hill House Care Home. Further engagement exercises are underway with regard to proposals to decommission services from Hitchin and Royston hospitals. • Local information on intermediate care can be found on the Hertfordshire Community NHS Trust37, NHS Hertfordshire38 and Hertfordshire County Council39 websites. • National guidance on intermediate care can be found in the Department of Health report Intermediate Care - Halfway Home40

www.hertschs.nhs.uk/services/adult/IntermediateCareTeams/default.aspx www.hertfordshire.nhs.uk/resource-centre/board-papers-from-meetings-held-in-public/334-nhs-hertfordshire-boardmeeting-in-public-held-on-wednesday-28-july-2010-at-200-pm.html 39 www.hertsdirect.org/services/healthsoc/adult/supphcs/homecare/enablement/ 40 Department of Health. Intermediate Care - Halfway Home. Updated Guidance for the NHS and Local Authorities 2009. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/documents/digitalasset/dh_103154.pdf 38

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This indicator is also included in the Adult Social Care Outcomes Framework. www.ic.nhs.uk/statistics-and-data-collections/social-care/adult-social-care-information/social-care-and-mental-healthindicators-from-the-national-indicator-set-2010-11-provisional-release

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Ensuring that people have a positive experience of care Summary

This domain looks at aspects of patient experience of care in different settings. There are thirteen indicators which are based on patients’ responses to surveys, all of which are run by the Care Quality Commission (CQC) except the GP Patient Survey. The existing surveys used to inform this indicator are: • the GP Patient Survey,

• Patients in a number of practices across Hertfordshire report significantly lower than average satisfaction scores.

• Patient experience in both Hertfordshire hospital trusts is reported to be worse than the national average for in patients, outpatients, and accident and emergency. • Hertfordshire hospital trusts were scored in the lowest fifth of units in the country for some aspects of maternity care. Figure 4.1 Patient satisfaction with care received by GP surgery, for East and North Hertfordshire Clinical Commissioning Group, April 2010 to March 201143

• the Adult Inpatient Survey, • the Outpatient Survey, • the Emergency Department Survey, • the Maternity Survey, • the Community Mental Health Services Survey. In addition to this, surveys are under development for bereaved carers and children and young people.

Primary care services 4.1.1 Patient experience of primary care (indicator 4a) The GP Patient Survey42 (GPPS) has been redesigned for 2011-2012 to include questions relating to patient experience of three areas which will be presented as separate indicators: • GP services, • GP out of hours services, • NHS Dental services. Previous GP patient surveys have measured patient experience of primary care services. This will not be directly comparable to the 2011-2012 GPPS data but provides a good indication of patient experience of primary care as shown in the graphs below. As discussed in Domain 2, the survey data require careful interpretation, but work is ongoing at national level to refine the surveys and develop new questions. More standardisation should mitigate the problems of bias resulting from incomplete response.

www.gp-patient.co.uk/

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Data from GP Patient Survey April 2010 - March 2011. Weighted responses to the question: “In general, how satisfied are you with the care you get at your GP surgery or health centre?” Percentage answering ‘very satisfied’ or ‘fairly satisfied’. www.indicators.ic.nhs.uk

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Figure 4.2 Patient satisfaction with care received by GP surgery, for Hertfordshire Valleys and Red House Clinical Commissioning Groups, April 2010 to March 201143

Figure 4.3 Patient experience of primary care services from GP Patient Survey, July to September 201144

• Patient experience of GP out of hours services received the lowest rating out of the primary care services. • Patient experience of primary care services in Hertfordshire are similar to the national average.

Primary care access • On average, satisfaction with care received at GP practices is slightly higher in Herts Valley and Red House CCGs than East and North Hertfordshire CCGs. • Up to 10 practices in each CCG record patient satisfaction at levels significantly higher or lower than the respective CCG average. • PCT level GPPS 2011-2012 data is available for the new patient experience questions for July to September 2011. Directly comparable historical data is not available and practice level data will not be published until July 2012.

Primary care access is broken down into two separate indicators; access to GP services and access to NHS dental services.

4.1.2 Access to GP services (indicator 4.4.i) A new question has been added to the 2011-2012 GPPS for this indicator. The GPPS 2011-2012 survey data for July to September 2011 reported that 76% rated the overall experience of making an appointment in Hertfordshire as ‘very good’ or ‘fairly good.’ The rate for England during the same period was 79%.

4.1.3 Access to dental services (indicator 4.4.ii) The GPPS 2011-2012 survey data for July to September 2011 reported that 94% of people were successful in getting an NHS dental appointment in the last two years. The England rate for the same period was 92%.

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Data from GPPS July-September 2011. Questions asked about “overall experience of GP surgery”, “overall experience of out-of-hours GP services” for those who said they had tried to call an out-of-hours GP service in the past 6 months and “overall experience of NHS dental services” for those who have tried to get an NHS dental appointment in the last 2 years. Hertfordshire response rate 41% (from 21,121), England response rate 38% (from 1,390,080). Results weighted. Capped lines represent 95% confidence intervals. www.gp-patient.co.uk/results/

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Hospital Care

4.3 Responsiveness to in-patients’ personal needs (indicator 4.2)

4.2 Patient experience of hospital care (indicator 4b) The Care Quality Commission Inpatient Services Survey measures the experiences of adult inpatients in Trusts in England. The survey asks a number of questions in five patient experience domains (access and waiting; safe, high quality co-ordinated care; better information, more choice; building closer relationships; clean, comfortable place to be) to produce an overall patient experience score for each Hospital Trust. Eight surveys have been run since 2001-2002 and nationally patient experience scores have stayed stable over the survey periods.

This indicator is a composite from five questions which describe a different element of the overarching theme “responsiveness to patients’ personal needs” in the CQC Inpatient Services Survey. Scores for England have stayed stable over the survey periods.

Figure 4.5. Responsiveness to in-patients’ personal needs score by Hospital Trust from Adult Inpatient Services Survey 201046

Figure 4.4 Patient experience of hospital care scores by Hospital Trust from Adult Inpatient Services Survey 201045

• Overall ENHT scored higher (64) than WHT (61) in responsiveness to in-patients personal needs. Both Trusts were below the score for England (67.3). However, the only significant difference between the two Trusts was in involvement in decisions about care/treatment.

• Scores for East and North Hertfordshire NHS Trust (ENHT) and West Hertfordshire Hospitals NHS Trust (WHT) were below the England score for each patient experience domain. • Overall patient experience score was 72 for ENHT and 71 for WHT. ENHT scored higher than WHT in each domain apart from access and waiting. • Of the 18 questions that make up this indicator, ENHT was among the 20% worst performing hospitals nationally for 11 of these questions and WHT 14 of the questions. For the remaining questions, both Trusts were among the intermediate 60% if Trusts. Neither Trust scored in the best performing 20% of trusts for any of these questions.

• ENHT were among the 20% worst performing Trusts for the questions relating to privacy and telling patients who to contact if worried about their treatment/condition after leaving hospital. • WHT were among the 20% worst performing Trusts for the questions relating to involvement in decisions about care/treatment, finding someone to talk about worries and fears with and telling patients about side effects of medication. • Improvements in the service are monitored via the Contract Monitoring route. Any issues for escalation would be addressed at the Contract Monitoring Meeting. • Feedback is encouraged from patients via a variety of routes such as Comment Cards, Patient Advice and Liaison Services, complaints and patient held trackers. National surveys ask questions in relation to personal needs and local surveys developed by individual providers reflect this also. The collation of responses is analysed and focus areas identified. Actions are defined and progress regularly monitored. In addition, the PCT undertakes a programme of Quality Assurance Visits where patient care is observed. Good practice and areas of improvement are identified and feedback provided to each provider.

46 45

Domain scores calculated as average of selected questions from the Care Quality Commission Inpatient Services Survey as specified in NHS Outcomes Framework 2012/13 Technical Appendix. Overall patient experience score is average of five domain scores. Responses were converted to scores on a scale of 0 to 100, with 100 indicating the best possible response. Patients were eligible for the survey if they were aged 16 years or older, had at least one overnight stay during June, July or August 2010 (the sampling period was chosen by the trust) and were not admitted to maternity or psychiatric units. National response rate 50%. Average sample size for selected questions: ENHT 342 (range 154 to 400), WHT 304 (range 127 to 363). www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/inpatient-survey-2010

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Questions for this indicator selected from the Care Quality Commission Inpatient Services Survey as specified in NHS Outcomes Framework 2012/13 Technical Appendix. Overall responsiveness to in-patients personal needs indicator is composite, calculated as average of 5 survey questions. Responses were converted to scores on a scale of 0 to 100, with 100 indicating the best possible response. Patients were eligible for the survey if they were aged 16 years or older, had at least one overnight stay during June, July or August 2010 (the sampling period was chosen by the trust) and were not admitted to maternity or psychiatric units. Capped lines represent 95% confidence intervals. National response rate 50%. Average sample size for selected questions: ENHT 334 (range 252 to 397), WHT 296 (range 209 to 362). www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/inpatient-survey-2010

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4.3.1

4.3.2

Patient experience of outpatient services (indicator 4.1)

Patient experience of accident and emergency (A&E) services (indicator 4.3)

This indicator is a composite constructed from five questions in the Care Quality Commission Outpatient Survey covering the stages of pre-visit, during the visit and the transition/post-visit period. The most recent Outpatient Survey was run in 2009, with similar surveys taking place in 2003 and 2004.

This indicator uses a composite measure which is calculated as the average score of five questions from the Care Quality Commission A&E survey. The most recent Outpatient Survey was carried out in 2008, with similar surveys taking place in 2003 and 2004.

Figure 4.6 Patient experience of outpatient services scores by Hospital Trust from Outpatient department survey 2009

• Overall ENHT scored higher (78) on the patient experience of outpatient services indicator than WHT (73). Both Trusts were below the score for England (78.6). There was a significant difference between the two Trusts for the question relating to telling patients who to contact if they are worried after they leave the hospital. • ENHT scores for each of the questions were among the intermediate 60% of Trusts.

Figure 4.7 Patient experience of A&E scores from Emergency Department Survey 200847

• Overall ENHT scored higher (78) on the average patient experience score of A&E services indicator than WHT (75). However both Trusts were below the score for England (80). There were no significant differences between the two Trusts for the questions. • ENHT were among the 20% worst performing Trusts for questions relating to explaining treatment in a way that could be understood, confidence and trust in doctors and nurses and involving patients in decisions about their care/treatment. • WHT were among the 20% worst performing Trusts for all 5 questions.

• WHT scores were among the worst performing 20% of Trusts for the questions relating to knowing what would happen during the appointment in advance, involving patients in decisions and telling patients who to contact if they were worried about their care/treatment after leaving hospital. • Improvements in this service are currently monitored via Patient Experience. Provision of letters received from the Outpatient Department is monitored through the Quality Schedule at E&NHT and WHHT and therefore discussed by senior Trust staff at both Quality Contract Meetings. Any issues for escalation would be addressed at the Contract Monitoring Meeting. The CQC National Outpatient Survey is undertaken by both Hertfordshire’s Acute Trusts and local surveys also take place. Results of both surveys are discussed at the Quality Contract Meetings where assurance will be given that actions are implemented and performance monitored. In addition, the PCT undertakes a programme of Quality Assurance Visits where patient care is observed. Good practice and areas of improvement are identified and feedback provided to each provider.

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Questions for this indicator selected from the Care Quality Commission Accident and Emergency Survey as specified in NHS Outcomes Framework 2012/13 Technical Appendix. Overall patients’ experience of A&E services indicator is composite, calculated as average of 5 survey questions. Responses were converted to scores on a scale of 0 to 100, with 100 indicating the best possible response. Data presented is from Emergency Department Survey 2008. Patients were eligible for the survey if they were aged 16 years or older and had attended the emergency department in January, February or March 2008. National response rate 40%. Average sample size for selected questions: ENHT 293 (range 174 to 336), WHT 297 (range 190 to 338). Capped lines represent 95% confidence intervals. www.nhssurveys.org/surveys/569

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4.3.3 Women’s experience of maternity services (indicator 4.5) This indicator is an average of six questions from the Care Quality Commission Survey of women’s experiences of maternity services covering the antenatal, labour and delivery and postnatal periods. Trust level data on the antenatal questions were not available from the most recent survey so the graph below refers to labour and delivery and postnatal periods only. The most recent maternity survey was carried out in 2010, a similar survey took place in 2007. Figure 4.8 Patient experience of maternity services scores from survey of women’s experiences of maternity services 201048

• New maternity provision opened at the Lister Hospital in October 2011 which includes specialist provision: birthing pools, midwifery led unit (for uncomplicated births), Obstetric Led Unit with care plans to safely manage women at high risk. • The Lister Hospital has further implemented action plans to reduce the caesarean rate which is currently 24% and is now at national average. Work continues to reduce induction rate; which is currently 27% (national average 22%).

• Service re-design of Community Midwifery provision (West Hertfordshire) is to be implemented within first quarter 2012.

Other surveys 4.4 Survey of bereaved carers (indicator 4.6) This indicator will be derived from a new National Bereavement Survey (VOICES) which has been piloted nationally. The indicator will measure the quality of life experienced by adults caring for those in the final three months of life. The questions to inform this indicator are still under consultation and it is anticipated that this will be an annual survey. Feedback from service users and carers and the monitoring of compliments and complaints forms part of the contract monitoring of end of life providers commissioned by NHS Hertfordshire. This indicator will be reviewed in anticipation of the 2012-2013 contracting round to ensure robust reporting and feedback is obtained throughout 2012-2013 from all providers. • The score for England includes antenatal questions and so is not directly comparable, and is not included. • Overall WHT scored higher (76) on patient experience of maternity services during labour and delivery and postnatal than ENHT (71). There was a significant difference between the two Trusts for treating the patient with kindness and understanding after the birth of their baby. • ENHT were among the 20% worst performing trusts for all questions except leaving the patient alone at a time that worried them. • WHT were among the 20% worst performing trusts for giving active support and encouragement for feeding the baby during the first few days. • The 2010 survey showed a marked improvement in patient experience from 2007. A Patient Survey Action Plan is in place to maintain and strengthen improvement which includes: • ante-natal care - scans clearly explained, • labour and birth - decision and choice surrounding birth, access to pain relief during birth and skin to skin contact post birth, • staffing during birth, • post natal care (in hospital), • breastfeeding support and infant feeding advice, • communication, being treated with kindness, involved with their care and spoken to in an understandable manner.

Questions for this indicator selected from the Care Quality Commission Maternity Survey as specified in NHS Outcomes Framework 2012-2013 Technical Appendix. Overall patients’ experience of maternity services indicator is composite, calculated as average of 4 survey questions. Responses were converted to scores on a scale of 0 to 100, with 100 indicating the best possible response. Data presented is from Survey of women’s experiences of maternity services 2010. Women were eligible for the survey if they had a live birth between 1-28 February 2010 and were aged 16 years or older. Women who had a home birth were also eligible. National response rate 52%. Average sample size for selected questions: ENHT 177 (range 175to 179), WHT 204 (range 202 to 205). Capped lines represent 95% confidence intervals. www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/maternity-services-survey-2010

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4.5 Patient experience of community mental health services (indicator 4.7) This indicator will be derived from the Care Quality Commission Community Mental Health Services Survey which has been run annually since 2003-2004. However the questions to inform this indicator have not yet been finalised. The last survey was published in 2011 for patients seen between July and September 2010. Overall, the care received from Hertfordshire Partnership NHS Foundation Trust in the last 12 months was given a score of 65 i.e. among the intermediate 60% of trusts49.

4.6 Children and young people’s experience of healthcare (indicator 4.8) A national Children’s Experience Questionnaire is currently under development from which this indicator will be derived.

Data from survey of people in contact with local NHS mental health services, including those who receive care under the Care Programme Approach (CPA). National response rate 33%. HPT sample size for selected question 274. www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/community-mental-health-survey-2011 Response converted to score on a scale of 0 to 100, with 100 indicating the best possible response. Question asked “Overall how would you rate the care you have received from NHS mental health services in the last 12 months?”

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Treating and caring for people in a safe environment and protecting them from avoidable harm Patients treated by the health service can expect to be treated as safely as possible, with the lowest possible rate of complications including healthcare associated infections (MRSA and C.difficile) acquired in hospital and the development of pressure ulcers. Summary • Trusts in Hertfordshire report more safety incidents than the average acute trusts, but the lower number of incidents where the degree of harm is ‘severe’ or ‘death’ suggests that this can be explained by a better reporting culture. • Much progress has been made locally and nationally in reducing healthcare associated infections. The focus has now shifted from the acute to the community and primary care settings.

5.1 Patient safety incidents reported (Indicator 5a) and patient safety incidents involving severe harm or death (Indicator 5b) • A patient safety incident is an unintended or unexpected incident that could have led or did lead to harm of one or more patients. The National Reporting and Learning System was established in 2003.

• The aim of measuring the total number of safety incidents reported to improve the culture of recognising and reporting safety incidents. A higher rate of total safety incidents reported may reflect a good reporting culture rather than more incidents. • The aim of measuring the number of patient safety incidents involving severe harm or death is to improve the safety of care and a high number of patient safety incidents involving severe harm or death may signal an area of concern. • The rate of reported safety incidents in the East and North Hertfordshire NHS Trust is similar to the England average, while the rate of reporting in West Hertfordshire Hospitals NHS Trust is higher, possibly reflecting a better culture of recognising and reporting safety incidents. • Rates of safety incidents in Hertfordshire involving severe harm or death are generally below the England average. • Actions to mitigate future incidents are identified via the Incident Reporting Process, and evidence of the implementation of these actions is required to ensure improvements are made and lessons are learnt. Figure 5.1 Patient safety incidents reported to the National Reporting and Learning Service per 100 admissions, in Hertfordshire, April 2008 to March 2010, by hospital trust51

• Reduction in pressure ulcers is an agreed regional priority and the incidence of pressure ulcers will be monitored through the NHS OF either through the NHS Safety Thermometer50 or by using routine hospital data (to be confirmed by the Department of Health).

www.ic.nhs.uk/services/nhs-safety-thermometer

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Rates are not adjusted for demographic or case mix differences between trusts or over time. The denominator for the 2012-2013 NHS Outcomes Framework indicator will be population rather than admissions. Source: National Reporting and Learning Service www.nrls.npsa.nhs.uk/resources

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5.2.2.1 Who is most affected? Figure 5.2 Patient safety incidents reported to the National Reporting and Learning Service, where degree of harm is recorded as “severe harm” or “death”, per 100 admissions, in Hertfordshire, April 2008 to March 2010, by hospital trust52

• Older people. • Men • Individuals with predisposing morbidities (e.g. renal failure, diabetes and immunosuppression).

• Medical procedures (e.g. surgical interventions, central or peripheral intravenous lines). • The majority of new cases of MRSA are now identified as originating from colonised patients in the community.

5.2.2.2 Progress in reducing MRSA rates: • Over the past few years there has been a noticeable decline in the number and rate of MRSA reports in NHS Hertfordshire. • Both East and North Hertfordshire Trust and West Hertfordshire Trust have shown a slight increase in the number of reported MRSA in 2010-2011 period, resulting in the rates per 100,000 bed days being higher than the national average. • Performance is monitored locally through the Commissioning for Quality and Innovation (CQUIN) payment framework or Quality Schedules for each healthcare provider. Figure 5.3 Incidence of Methicillin-resistant Staphylococcus aureus in Hertfordshire, 2007-2008 to 2010-2011, by hospital trust, males and females of all ages combined53

5.2 Incidence of healthcare associated infection (Indicator 5.2)

5.2.1 What are health-care associated infections? MRSA and Clostridium difficile (C. difficile) infections may be acquired in healthcare settings including hospitals and pose a serious risk to vulnerable patients.

5.2.2 MRSA infection surveillance: The Staphylococcus aureus organism can colonise the skin and can survive without causing infection - a state known as colonisation. A patient becomes clinically infected if the organism invades the skin or deeper tissues and multiplies; infection of the bloodstream is referred to as MRSA bacteraemia. It is not known how many healthy people in the community are colonised with MRSA but studies suggest that the number is increasing; community strains of MRSA are likely to play a larger role in the future.

Trust-specific rates should be interpreted with caution as small numbers of reported incidents lead to instability in the estimates. Rates are not adjusted for demographic or case mix differences between trusts or over time. The denominator for the 2012-2013 NHS Outcomes Framework indicator will be population rather than admissions. Source: National Reporting and Learning Service www.nrls.npsa.nhs.uk/resources

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Data from regional extract from national mandatory surveillance system www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4085951

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5.2.3

5.2.3.3

Clostridium difficile infection surveillance C. difficile is part of the normal gut flora of many healthy people and causes no harm at all. However, certain antibiotic therapies can upset the gut flora balance which results in the C. difficile causing infection.

What is being done now? • The main focus of NHS Herefordshire for 2012 is to reduce the number of cases in the community. • The strategy for this involves educating and raising awareness, informing health professionals about recent advances and best practice changes with regard to prescribing practices

5.2.3.1

• NHS Hertfordshire has also introduced a QOF payment to support regular audits of GP prescribing practices. The findings from these audits will be fed back to the GPs to stimulate a change in antibiotic prescribing.

Who is most affected? • 80% over 65 years. • Over 50% are female. • Individuals with predisposing morbidities (e.g immunosuppression). • Individuals who have had repeated enemas and/or gut surgery.

5.2.3.2

5.3 Admission of full term babies to neonatal care (Indicator 5.5) • The NHS Outcomes framework indicator will be the proportion of all full term babies (37 weeks or more gestation) admitted to neonatal intensive care, but these data are not currently not published

Progress in reducing C. difficile rates:

• The aim is to measure improvements in the quality and safety of antenatal and intrapartum care (in reducing the number of full term babies going on to require neonatal intensive care)

• NHS Hertfordshire has been set a target to reduce the C. difficile infection rate by 50% compared to the baseline rate from 2007, by March 2011. To date we have achieved a 73% rate reduction and the current rate is one of the lowest in the East of England.

• More information can be found at the Neonatal Networks website: www.neonatal.org.uk

• In 2007 West Hertfordshire Hospital Trust had much higher C. difficile infection rate per 100,000 bed days than the national average, but recent figures show a similar rate. • During the period 2009-2010 and 2010-2011 both East and North Hertfordshire Trust and West Hertfordshire Trust have managed to reduce the Trust apportioned rate of infection from 82 to 56 and 57 to 54 cases per 100,000 bed days respectively. This reduction was associated with raising awareness of antibiotic prescribing in both the hospital Trusts and the community as well as auditing infection control practices. • Performance is monitored locally through the Commissioning for Quality and Innovation (CQUIN) payment framework or Quality Schedules for each healthcare provider. Figure 5.4 Incidence of Clostridium difficile in Hertfordshire, 2007-2008 to 2010-2011, by hospital trust, males and females 2 years and over54

Data from regional extract from national mandatory surveillance system www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1179745282408

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Appendix

Acknowledgements

Ambulatory care sensitive conditions

This report reflects the collective efforts of the following people.

One of following conditions (with certain procedure based exclusions): Vaccine-preventable: including influenza and pneumonia Chronic: diabetes complications, nutritional deficiencies, iron deficiency anaemia, hypertension, congestive heart failure, angina, chronic obstructive pulmonary disease, asthma

Hilary Angwin

Keir Mann

Jeni Beard*

Laura Maynard-Smith*

Acute: dehydration and gastroenteritis, convulsions and epilepsy, ear, nose and throat infections, dental conditions, perforated/bleeding ulcer, ruptured appendix, pyelonephritis, pelvic inflammatory disease, cellulitis, gangrene

Sue Beck

Linda Mercy

Denise Boardman

Raj Nagaraj

Joel Bonnet

Gordon Pownall

A full definition can be found here: www.nhscomparators.nhs.uk/NHSComparators/NHS%20Comparators/downloads/amb ulatory_care_sensitive_groups_with_ICD10_codes.xls

Ian Brown* Kate Chand Holly Christensen* Tracey Cooper Richard Garlick* Barbara Gill Sara Godward* Gill Goodlad Raymond Jankowski Rachel Joyce

*Editorial team

Annual Report 2012

Umair Rathore Kevin Ritchie-Oâ&#x20AC;&#x2122;Dell* Louise Savory* Louise Smith* Jessica Stokes* Miranda Sutters* Robin Trevillion Nicky Williams Peter Wright