Frailty Care Heatmaps

As part of our analysis of the Frailty indicators within the GP Core Contract data published by NHS Digital on 17 May 2018, we have constructed 'heatmaps' to help compare implementation of the contract across different regions, Strategic Transformation Partnership (STP) areas, Clinical Commissioning Groups (CCGs) and GP Practices.  The source data is for each GP practice and so each level above that is an aggregation of the GP practices within that CCGs, then the CCGs within an STP area, and the STP areas within ther NHS England Regions.

NHS England Regions

 

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The NHS England regions heatmaps is provided by way of example.  There is limited variability due to the high level aggregation, although London's markedly younger population stands out.  Otherwise, most metrics are relatively similar alhtough the South has proportionally fewer referrals to falls clinics for people living with moderate or severe frailty and coded as having had a fall.  By contrast London has the highest proportion of referrals but the lowest percent of coded fallers.


STP Areas

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Spotlight on: West, North and East Cumbria

  • The smallest STP area with 40 practices and just over 72,000 registered patients aged 65 and over.  
  • They have made most progress (nationally) on assessing for frailty (81%) and are in line with the North region's average for the percent of population aged 65 and over diagnosed with moderate or severe frailty (11%) which is higher than England average (9%).  
  • Their diagnosis rate is also in line with regional average (67%) and above England average (58%), whilst the coded case mix of moderate and severe is also average (2.0), the local GP practices appear to have identified proportionally more frailty than dementia (a ratio of 2.7)  compared to both regional aevrage (2.4) and England average (2.2)
  • Their progress on medication reviews is average (66%)
  • Whilst they have coded a higher proportion of their population living with moderate or severe frailty as fallers (14% compared to 10% regional average), their onward referrals to falls clinics are lower (11% compared to 25% regional and national average).  
  • They have also made less progess on gaining consent to activate enriched Summary Care Records (SCR).

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Spotlight on: Nottinghamshire

  • A relatively 'average' STP area with 138 practices and just over 180,000 registered patients aged 65 and over.  
  • They have made below average progress (regionally and nationally) on assessing for frailty (17%) but are slightly higher (11%) than regional average for the percent of population aged 65 and over diagnosed with moderate or severe frailty (10%) which is higher than England average (9%).  This suggests a relatively targeted approach to assessment.
  • Their diagnosis rate (67%) is ahead of the regional average and above England average (58%), whilst the coded case mix of moderate and severe is also below average (1.5) indicating that they have also focused on those with identfiying and assessing those with severe frailty more than average.
  • Their progress on medication reviews is broadly average (68%), as is their coding of population living with moderate or severe frailty as fallers (10% compared to 11% regional and national average)
  • Their onward referrals to falls clinics are amongst the highest of all STP areas (73% compared to 25% regional and national average).  
  • They have made less progess on gaining consent to activate enriched Summary Care Records (SCR) (9% compared to regional average of 14%).

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Spotlight on: Gloucestershire

  • Similar in size to a Cornwall and the Isles of Scilly and also Somerset with around 130,000 registered patients aged 65 and over, although more GP practices than either comparable area and a lower proportion of registered list aged 65 and over (21%) than the two comparable STP areas (both 24%).
  • They have made less progress assessing for frailty (21%) than regional and England average - although more than Cornwall and the Isles of Scilly - and have a lower than average percent of population aged 65 and over diagnosed with moderate or severe frailty (6%) currently.  
  • Their diagnosis rate is also low (38%) again potentially reflecting the low numbers assessed.  Coded case mix of moderate and severe is in line with the average, although the local GP practices appear to have identified proportionally more dementia than frailty (a ratio of 1.5)  compared to both regional aevrage (2.1) and England average (2.2)
  • Their progress on medication reviews is around average (69%)
  • Whilst they have coded a higher proportion of their population living with moderate or severe frailty as fallers (16% compared to 12% regional average), their onward referrals to falls clinics are broadly average for the region (13%) but lower than 25% national average.  
  • They have made some of the most progess on gaining consent to activate enriched Summary Care Records (SCR), albeit on a lower than average proprtion assessed and diagnosed.

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Spotlight on: North West London

  • Largest of the London STP areas in terms of both GP Practices and registered patients aged 65 and over, with London-wide average proportion of registered list aged 65 and over (11%) which is significantly lower than all other regions.
  • They have made slightly less progress assessing for frailty (22%) than regional and England average, but have alomost twice the average percent of population aged 65 and over diagnosed with moderate or severe frailty (14%) currently.  
  • As a result, their diagnosis rate is one of the highest across all STP areas (85%) with coded case mix showing a higher proportion of moderate diagnoses than regional or national average (2.4 compared to 2.0).  Local GP practices also appear to have identified proportionally more frailty than dementia (a ratio of 3.1)  compared to both regional aevrage (1.9) and England average (2.2)
  • Their progress on medication reviews is in line with the London average (64%) which is slightly lower than national average (66%)
  • They have the lowest proportion of their population living with moderate or severe frailty coded as fallers across all STP areas (4% compared to 12% regional average), their onward referrals to falls clinics is one of the highest (94%).  
  • They have made below average progess (12% compared to 15%) on gaining consent to activate enriched Summary Care Records (SCR), albeit on a proportionally higher number of people diagnosed with moderate or severe frailty.

These heatmaps contain information from NHS Digital, licenced under the current version of the Open Government Licence.

Further heatmaps showing the breakdown by CCG within an STP area or GP Practice within a CCG are available on request.  Please contact david@fusion48.net

Links to further information: