Integrated Care Partnership PCN

Patients aged 65+ comprise 21.1% of the list alongside 19.6% non-White resident diversity

The single-practice PCN registers 30,537 patients, with 21.1% (6,451) aged 65+, above Epsom and Ewell (18.3%), NHS Surrey Heartlands ICB (18.8%), and England (17.9%). Children aged 0–17 comprise 20.7% (6,314), matching the borough (20.7%) and above the ICB (20.4%) and England (19.6%). Based on Census usual residents rather than registered patients, 19.6% identify as ethnic minorities, led by Asian / Asian British residents at 10.9% (borough 11.4%, ICB 7.7%, England 9.6%). Catchment care homes number 35 with 900 beds, though resident occupancy is unconfirmed. Population growth is projected at 1.8% to 2030 under unverified methodology.

Average IMD decile is 8.5, yet 3.9% of registered patients are in Core20

Average IMD decile is 8.5, matching Epsom and Ewell (8.5) and above NHS Surrey Heartlands Integrated Care Board (7.9) and England (5.5). The Core20 share is 3.9%, above Epsom and Ewell (2.0%) and the ICB (0.8%), but below England (21.0%). Although 0 of 49 associated LSOAs are in national deciles 1 or 2, 1,200 practice-estimated patients (1,129 estimated residents: 314 aged 0-17, 715 aged 18-64) live in Core20 areas. Because no associated LSOAs fall into deciles 1 or 2, area-based outreach may not identify Core20 patients without practice-level postcode auditing.

PLUS groups and inclusion health

The PCN records 234 learning disability patients (0.7% prevalence, above England's 0.6%) and 269 severe mental illness patients (0.8%), representing 55.7% and 42% of Epsom and Ewell registers. Across the borough, unpaid care is 8.0% (a PCN ceiling of about 2,400) and rough sleeping was zero in Autumn 2025, though neither figure measures registered patients directly.

Severe mental illness: physical health checks

On the 269-patient SMI register, physical health checks trail England across blood pressure (78.7% vs 83.4%), BMI (75.7% vs 82.1%), and alcohol recording (67.3% vs 81.8%). Systematic recall could address unverified physical health check gaps.

Clinical focus: hypertension and lipids

Hypertension case-finding and control

Recorded hypertension prevalence rose +22.4% over three years (England +5.6%) to 16.6% (5,247 patients), above England (15.2%), Epsom and Ewell (15.1%), and the ICB (14.3%). Blood pressure control in patients aged under 80 increased +13.1% (England +3.2%) to 65.0% (England 67.8%). Conversely, blood pressure control in patients aged 80 and over fell 4.1% (England +2.2%) to 71.1%, trailing England (81.2%) by 10.1 percentage points, the ICB (79.9%) by 8.8 percentage points, and the borough (76.1%) by 5.0 percentage points. Older patients with hypertension experience lower blood pressure control than national benchmarks indicate, making clinical review and home monitoring for patients aged 80 and over an immediate priority.

Lipids and statins

Lipid therapy reaches 58.7% of CKD patients (England 70.3%) and 58.6% with QRISK ≥ 20% (England 63.6%). In 2026, prescribing for patients aged 65+ was 4,990 items per 1,000 (England 18,056). Fewer at-risk patients receive lipid-lowering therapy than national rates imply, making a systematic treatment review a key priority.

For lipid-modifying drugs, the PCN's 2026 cost per item was £2.40 against £1.86 in England and £2.24 in the ICB. Across 32,190 items, the PCN spent £17,383 more than at England's unit cost and £5,150 more than at the ICB's. Higher unit costs than benchmarks indicate an opportunity to review lipid-modifying formulary choices alongside expanding treatment reach.

Clinical focus: respiratory, cancer register and children

Respiratory

Asthma reviews rose +615.7% (England +4.4%) over three years to 59.0% (England 65.7%), leaving about 740 unreviewed patients on the 1,795-patient register. Youth asthma second-hand smoke recording reached 67.7% (England 78.8%). Conversely, COPD reviews fell 21.2% (England +2.8%) over three years to 61.1% (England 76.4%, ICB 77.7%), and smoking cessation offers fell 8.2 pp (England +0.1 pp) to 87.8% (England 94.2%). Expanding structured review capacity could address these persistent chronic respiratory shortfalls.

Cancer register and children's immunisation

Recorded cancer prevalence is 5.3% (1,663 patients), above England (3.8%) and the ICB (4.5%). In childhood immunisations, MMR dose 1 coverage at 24 months is 86.9%, trailing NHS Surrey Heartlands ICB (91.4%) and England (88.3%), sitting 8.1 pp below the 95.0% target. At age 5, MMR dose 2 coverage is 93.1%, 4.1 pp below first-dose coverage (97.2%). Targeted catch-up clinics could close these childhood vaccination shortfalls.

Early cancer diagnosis

Cancer stage is reported at ICB level rather than PCN level. In 2022, NHS Surrey Heartlands ICB diagnosed 61.4% of staged cancers at stage 1 or 2 (2,955 of 4,810), exceeding England (55.3%) but sitting 13.6 pp below the national 75.0% ambition. Reaching 75% across the ICB requires about 650 extra early-stage cases a year. Known stage was recorded for 67.7% of cancers (England 67.0%). At PCN level, cervical screening coverage is 64.9% (ICB 69.3%, England 66.8%) and breast screening coverage is 69.7% (ICB 71.2%). Screening coverage below ICB benchmarks highlights preventive pathway opportunities.

Cancer waits, diagnostics and community services

Cancer waits and diagnostics, Jul 2026 (provisional)

In July 2026, Epsom and St Helier University Hospitals NHS Trust achieved 86.8% on the cancer 62-day standard, exceeding the 85.0% target, St George's University Hospitals NHS Foundation Trust (83.0%), Kingston and Richmond NHS Foundation Trust (75.3%), NHS Surrey and Sussex Integrated Care Board (71.5%), and England (71.2%). The trust met the 28-day faster diagnosis standard at 89.7% (England 79.3%) and 31-day standard at 99.2% (England 92.5%). All-test diagnostic 6+ week waits were 6.8% (England 23.1%), though colonoscopy was 33.0% (England 30.8%). Local acute pathways remain timely, though endoscopy waiting lists require monitoring.

Good patient experience is 81.8% despite phone access trailing England at 48.9%

In 2025/26, Integrated Care Partnership - Och achieved 93.6% overall QOF achievement (England 92.5%) and 98.8% in the clinical domain (England 97.1%). However, its personalised care adjustment rate across all domains was 14.2%, above England (10.0%) by 4.2 percentage points. Internal practice audits would be required to verify whether adjustments reflect appropriate exceptions or review shortfalls.

Fourteen of 25 compared measures trail England's three-year trend, led by COPD reviews

Across 25 compared measures, 14 trail England's three-year change. The widest lags are in routine care processes: COPD reviews fell 21.2% (England +2.8%), alcohol recording for patients with psychosis fell 6.8 pp (England +5.4 pp), and smoking cessation offers fell 8.2 pp (England +0.1 pp). Blood pressure control in patients aged 80 and over also fell 4.1% (England +2.2%). Conversely, asthma reviews rose +615.7% (England +4.4%), blood pressure control under 80 rose +13.1% (England +3.2%), and non-frail diabetes HbA1c control rose +10.4% (England +4.4%), showing delivery gains remain uneven across clinical pathways.

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