East Elmbridge PCN

Aged 65+ patients comprise 19.4% of registrations alongside 15 catchment care homes

East Elmbridge PCN registers 59,683 patients. Older adults aged 65+ represent 19.4% of registrations (11,569 patients), above Elmbridge (17.9%), NHS Surrey Heartlands ICB (18.8%) and England (17.9%), alongside 15 catchment care homes. Children aged 0-17 account for 21.2% (12,676 patients), compared to 21.7% in Elmbridge, 20.4% across the ICB and 19.6% nationally. Census usual residents in associated areas are 86.5% White (Elmbridge 86.1%, ICB 85.3%, England 81.1%) and 6.6% Asian or Asian British (Elmbridge 6.5%, ICB 7.7%, England 9.6%). Projected list growth is 3.7% to 2030 (Elmbridge 3.6%, ICB 4.9%, England 2.3%), though projection methodology is unverified.

East Elmbridge records an average IMD decile of 8.8 and 0.0% Core20 patients

East Elmbridge PCN has an average IMD decile of 8.8, above Elmbridge (8.6), NHS Surrey Heartlands ICB (7.9) and England (5.5). Registered Core20 share is 0.0% across practices (Elmbridge 0.0%, ICB 0.8%, England 21.0%), representing 0 estimated patients. Practice deciles range from 8.1 at Vine Medical Centre to 9.8 at Lantern Surgery. Among 35 associated catchment LSOAs, 3 are in national decile 1 and 1 is in decile 2. Inequality targeting may therefore focus on clinical cohorts and resident LSOA pockets rather than registered deprivation.

PLUS groups and inclusion health

Inclusion registers hold 497 severe mental illness patients (43.9% of Elmbridge's total) and 247 with learning disabilities (49.7% of borough cases), alongside 15 catchment care homes (699 beds). Unextrapolated borough data records 7.4% unpaid carers and 12 rough sleepers. Recorded prevalence sits at 0.8% for severe mental illness (Elmbridge 0.7%) and 0.4% for learning disabilities (Elmbridge 0.3%); clinical review would test whether this reflects concentrated caseload demand.

Severe mental illness: physical health checks

Severe mental illness register prevalence is 0.8% (497 patients). Blood pressure was recorded for 85.6% (England 83.4%) and BMI for 83.3% (England 82.1%). Smoking cessation support was offered to 91.5%, trailing England's 94.2%.

Clinical focus: hypertension and lipids

Hypertension case-finding and control

Recorded hypertension prevalence is 13.2% (8,147 patients), above Elmbridge (12.6%) but below the ICB (14.3%) and England (15.2%). Practice prevalence ranges from 11.4% at Esher Green Surgery to 14.6% at Glenlyn Medical Centre. Blood pressure control for patients under 80 is 65.5%, trailing Elmbridge (66.7%), England (67.8%) and the ICB (68.1%), despite 3-year control growth of +4.5% (England +3.2%). Additionally, hypertension patients with a recent blood pressure check reached 89.4%, slightly behind England (90.0%). Observation periods and population bases are not supplied by the source. Under-80 blood pressure control sits below national benchmarks, pointing to an opportunity to prioritise clinical titration and routine review for working-age hypertensive patients.

Lipids and statins

Lipid-lowering therapy reaches 54.4% of patients with QRISK ≥ 20% (England 63.6%), 62.6% with CKD (England 70.3%) and 67.5% with diabetes without CVD (England 73.2%), with adult prescribing at 1,427 items per 1,000 (England 4,100 rate). Fewer at-risk patients are on lipid-lowering therapy than England benchmarks imply, so prioritising recall audits is an operational opportunity.

Annual spend on lipid-modifying drugs is £109,991 across 56,118 items at £1.96 per item: £7,857 more than England's unit cost (£1.82) but £12,346 less than the ICB's (£2.18). Across 94,943 cardiovascular items, spend is £385,469. Unit costs trail the ICB while exceeding England, suggesting formulary review could deliver marginal efficiencies without compromising treatment appropriateness.

Clinical focus: respiratory, cancer register and children

Respiratory

Asthma prevalence is 5.8% (3,414 patients; England 6.6%). Annual reviews rose +9.6% over 2023 to 2025 to 68.0%, above England (65.7%) and Elmbridge (61.6%), though about 1,100 patients remain unreviewed. Asthma management items for ages 5-19 are prescribed at 666 per 1,000, below England (1,488 rate). COPD prevalence is 1.1% (647 patients; England 1.9%), with reviews at 77.6% (England 76.4%). Lower youth prescribing is consistent with lower medication intensity or milder disease, but has not been confirmed locally.

Cancer register and children's immunisation

The cancer register records 2,890 patients (4.7% prevalence, above England's 3.8%). Childhood primary immunisation is strong, with 24-month 6-in-1 at 98.5% and MMR dose 1 at 95.5%. At age 5, coverage falls below the 95.0% target: MMR dose 2 reaches 90.7% (a 2.9 pp difference from MMR dose 1 at 93.6%) and 4-in-1 booster reaches 90.0%. Slower pre-school booster uptake leaves children under-protected before school entry.

Early cancer diagnosis

In 2022 across NHS Surrey Heartlands ICB, 61.4% of staged cancers (2,955 of 4,810 known stage) were diagnosed at stage 1 or 2, above England (55.3%) but 13.6 pp below the 75.0% national ambition, representing about 650 extra cases needed annually. Known-stage coverage was 67.7% (4,810 of 7,106 registered cancers). This system metric cannot be treated as PCN performance. Locally, PCN breast screening coverage is 67.3% (ICB 71.2%, England 69.9%), while cervical screening at ages 25 to 49 is 69.2% after falling 2.7% over 2023 to 2025 (England -1.0%). Lagging screening uptake across the PCN may delay early detection across female cohorts.

Cancer waits, diagnostics and community services

Cancer waits and diagnostics, Jul 2026 (provisional)

At Kingston and Richmond NHS Foundation Trust in Jul 2026 (provisional), 75.3% of cancer pathways met the 62-day referral to treatment standard (standard 85.0%), above NHS Surrey and Sussex ICB (71.5%) and England (71.2%). Nearby trusts recorded higher 62-day performance, including Epsom and St Helier University Hospitals NHS Trust (86.8%) and Chelsea and Westminster Hospital NHS Foundation Trust (90.4%). On the 28-day faster diagnosis standard, Kingston and Richmond reached 80.1%, exceeding the 75.0% standard, alongside the ICB (79.3%) and England (79.3%). These figures describe secondary care pressures, not PCN referral performance.

Patient experience and vaccination achievement vary sharply across the seven practices

In 2025/26, overall QOF achievement ranged from 89.5% at Thorkhill Surgery to 99.6% at Lantern Surgery. The vaccination and immunisation domain showed a 36.7 pp spread across practices, from 63.3% at Glenlyn Medical Centre to 100.0% at Littleton Surgery, alongside personalised care adjustment rates between 1.6% at Esher Green Surgery and 12.2% at Littleton Surgery.

Heart failure reviews fell 6.8% while nine measures lagged national three-year gains

Nine clinical indicators trail England's three-year trajectory. Heart failure reviews fell 6.8% over 2023 to 2025 (England +8.7%), trailing by 15.5 points, while non-frail diabetes HbA1c control fell 0.01% (England +4.4%). Conversely, East Elmbridge PCN achieved three-year gains across inclusion pathways: alcohol recording on the mental health register rose +13.4 pp (England +5.4 pp), annual body mass index checks increased +9.8 pp (England +5.1 pp), and asthma reviews grew +9.6% (England +4.4%).

What the data can't tell us: gaps and local assets

Options for the PCN

Each option in full

Provenance and audit trail

Figures are the profile's, drawn from Coplug indicator tables: census, deprivation and QOF measures, MHCLG, Rough sleeping snapshot in England: autumn 2025, OHID, Fingertips diabetes by frailty status: HbA1c control (93712, 93713) and OHID, Fingertips falls: emergency admissions, 65+ and 65 to 79 (22401, 22402), accidental-fall deaths (94002). Every recommended action and option is the profile's own; the evidence-base statements that support them — what each register is the cohort for, and the national policy it serves — are quoted from Coplug's indicator catalogue. No recommendation in this report is authored outside the profile and that catalogue. ICB- and provider-level data (page 8) describes the system the PCN sits in and is not read as PCN performance.

Data sources

Every figure in this profile comes from a dataset below, at the level and period stated. Nothing published above PCN level is read as PCN performance.

Methods, data-quality notes and limitations