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The Heart Disease Delivery Plan of Powys Teaching Health Board 2013 – 2016: 2014/15 update 1. Background “Together for Health – a Heart Disease Delivery Plan” was published by the Welsh Government in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government’s expectations of the NHS in Wales to prevent avoidable heart disease and plan, secure and deliver high quality personcentred care for anyone affected by heart disease. It focuses on meeting population need, tackling variation in access to services and reducing inequalities in health outcomes across 6 themes. For each theme it sets out: Delivery aspirations for the prevention and treatment of heart disease Specific priorities for 2013-2016 Responsibility to develop and deliver actions to achieve the specific priorities Population outcome indicators and NHS assurance measures Following the publication of the National Heart Disease Delivery Plan (HDDP), all Health Boards were required to develop and agree local HDDPs for submission to Welsh Government by 31 December 2013. The HDDP for Powys was submitted to Welsh Government in advance of the deadline and was approved by Board on 19th February 2014. In October 2014, Welsh Government requested that Health Boards update their current plans and submit a refresh reflecting the current position by the end of December 2014, following Board approval. In order to inform this update a midyear review was carried out in August/September 2014. The PtHB Director of Planning is currently reviewing local leadership and delivery arrangements for the national delivery plans, many of which are drafted from a “provider” rather than “commissioner” perspective. 2. Powys Health Board Delivery Plan The Powys Health Board produced its first delivery plan in 2013. In our delivery plan we set the following priorities for 2014: The promotion of healthy hearts The timely detection of heart disease Fast and effective care Living with heart disease Improving information Targeting research Page 1 of 32 In delivering heart disease services, there are a number of service improvements that we have implemented locally that have had a real impact on both patient care and outcomes. An example of this is the ongoing development of smoking cessation pathways for pre-operative patients. 3. The Vision: Our vision for heart care is for: People of all ages to have as low as possible a risk of developing heart diseases and, where they do occur, an excellent chance of living a long and healthy life, wherever they live in Wales. Wales to have incidence, mortality and survival rates for heart disease which are comparable with the best in Europe We will use a range of indicators to measure success. These are being developed and will be refined over time and will include indicators such as: 4. Coronary disease prevalence rates: % patients under 75 living with coronary heart disease Circulatory disease mortality rates under 75 per 100,000 population. Survival following out of hospital cardiac arrest Cardiovascular death in relation to average life expectancy - potential years of life lost. The Drivers: There are good reasons for heart disease to be a key priority area for Powys Health Board According to the latest figures available from the Welsh Health Survey, 19% of adults are being treated for high blood pressure and 8% for any heart condition, excluding high blood pressure. The most significant1 cause of heart-related ill health and death in Powys is coronary heart disease. Although death rates in Wales have been falling over the last 3 decades, they remain around 15% higher than in England 2. In addition, death rates vary significantly across Wales; the death rate in the most deprived fifth of wards is almost a third higher than in the least deprived fifth3 - showing the pronounced impact of poverty and the socio-economic determinants of health. While coronary heart disease is a largely preventable cause of ill health and death, the latest figures for Powys show that major risk factors remain high4: 19% of adults report smoking (compared with 21% across Wales). 1 Public Health Wales Observatory, using ADDE (ONS) 2014 2 Trends in Coronary Heart Disease 1961-2011, British Heart Foundation, 2011 3 The Cardiac Disease National Service Framework for Wales, Welsh Government, 2009 4 Welsh Health Survey 2013, Welsh Government statistics released September 2013 Page 2 of 32 14% of adult non-smokers report regular exposure to other people’s tobacco smoke indoors 57% of adults were classed as overweight or obese; amongst children the figure was 23.2% (of whom 9.9% were obese)5 40% of adults reported drinking above guidelines on at least one day in the past week Only 35% of adults reported being physically active on 5 or more days in the past week These risk factors highlight the focus on coronary heart disease and promotion of healthy hearts as a theme. Coronary heart disease is, however, just one part of the picture and this Delivery Plan, covers heart conditions more broadly. It highlights the importance of providing high quality detection and treatment of all major heart diseases, including: 5. Heart failure (predominantly caused by coronary heart disease) Arrhythmia management, including management of atrial fibrillation (frequently a consequence of coronary disease) Congenital heart disease (in children and adults) Inherited or idiopathic cardiac conditions, including cardiomyopathies What do we want to achieve? In line with national expectations, the Powys Heart Disease Delivery Plan sets out action to improve outcomes from heart disease in the following key areas, up to 2016: 6. The promotion of healthy hearts The timely detection of heart disease Fast and effective care Living with heart disease Improving information Targeting research Organisational Profile and summary of current service provision Powys teaching Health Board is one of seven integrated Health Boards in Wales and is responsible for both commissioning and providing health care services to the Powys population of around 132,000 people. In fulfilling its responsibilities, Powys teaching Health Board faces a number of challenges: A relatively small population (~4% of the Welsh total) living in a large county of >5,000km2 (~25% of the landmass of Wales). Powys is around 140 miles long, with a travel time by car of around three hours 5 Childhood Measurement Programme Annual Report 2012/2013 Page 3 of 32 north to south. 88% of the Powys landmass is classified as agricultural land and the population is sparse (<2 people/hectare on average); only one town has more than 10,000 people. 50% of the population live in a hamlet or village; 23% of the population report that their nearest family member lives at least 50 miles away Population projections show that by 2033, the Powys population aged over 75 years will have increased significantly (Figure 1) Although much of Powys is a beautiful rural environment, many parts are hilly or mountainous. Coupled with slow travel times on some roads, the situation presents obvious challenges to the timely delivery of health care, including access to life-savings interventions for cardiovascular disease Powys teaching Health Board directly provides non-specialist healthcare services, through its network of community services and community hospitals. The organisation commissions acute hospitalbased services from a complex range of secondary and tertiary care providers in both England and Wales. Taken together, in this regard, the Health Board is unique within Wales Figure 1: Powys: > 75 Years Population Projections In addition, there are significant health inequities and inequalities within Powys. Further, evidence from the Welsh Health Survey that Powys adults are often relatively low users of health care services compared to the rest of the Welsh population. (Table 1) Page 4 of 32 Table 1: Health Service Use in Powys and Wales Health service use GP in the past 2 weeks Attended casualty in the past twelve months In hospital as an inpatient in the past twelve months Attended outpatients in the past twelve months Saw a pharmacist in the past twelve months Attended a dentist in the past twelve months Attended an optician in the past twelve months Source: Welsh Health Survey, 2013 (Welsh Government) Powys 15% 14% 7% 31% 65% 77% 49% Wales 17% 17% 9% 32% 70% 70% 50% Improving Health and Wellbeing Health improvement priorities are articulated in the Powys Integrated Medium Term Plan 2014-2017, which has determined the local delivery of actions to improve health and wellbeing through a partnership approach. This framework sets out the Powys response to the ten challenges identified in Welsh Government’s public health strategy “Our Healthy Future”: Stopping the growth in health inequities Reducing smoking rates Increasing physical activity rates Reducing unhealthy eating Stopping the growth in harm from alcohol and drugs Reducing teenage pregnancy rates Reducing accident and injury rates Improving mental well being Improving health at work Increasing immunisation rates to recommended levels More recently, the primary prevention transformation programme for Powys further prioritises five key deliverables, each of which will potentially have direct or indirect impact on heart disease: to reduce smoking prevalence; to reduce alcohol misuse; to reduce childhood obesity; to increase the resilience of young people (in line with Friedli and Parsonage); and to increase rates of immunisation. There has already been significant stakeholder engagement on the development and further roll-out of these priorities, in the context of the Powys teaching Health Board Integrated Medium Term Plan 2014/17. In this context, it should be noted that a range of actions are in hand to improve local performance of Smoking Cessation Services, which are currently failing to deliver the Welsh Tier 1 smoking cessation target in Powys. Page 5 of 32 Overview: The Delivery of Services for Heart Disease Primary and Secondary Care Primary care based heart disease treatment services in Powys are provided from 17 general practices across the north, mid and south localities. Delivery is in line with the requirements of the national General Medical Services contract and the Quality and Outcomes Framework (as confirmed by the Powys Heart Disease Delivery Plan Needs Assessment). Powys teaching Health Board has also implemented a number of Local Enhanced Service agreements with Powys general practices, to further improve the local prevention and management of cardiovascular disease, including for heart failure and diabetes, which all practices in Powys have now signed up to. Out of hours GP care is provided by Shropdoc, whose main organisational HQ is in Shrewsbury, Shropshire. The Health Board has also supported the implementation of the MSDi tool across general practice in Powys. Although not specific to heart disease, this tool will improve the identification and management of patients with complex/multiple health care needs going forward. Although there are open access arrangements for primary care to some diagnostic interventions for heart disease in Powys (including for BNP testing for heart failure and echocardiography), these arrangements are not yet uniform. Primary care provision is in turn supported by a range of community services directly provided by Powys teaching Health Board, including community nursing teams (with cardiac nurse specialists), community hospitals and other services. The cardiac rehabilitation programme is delivered by specialist nurses working from a range of community hospital and leisure centre venues across Powys, supported by physio- and occupational therapists and BACR instructors. Powys teaching Health Board commissions heart disease services at secondary care level through its clinically-led locality-based approach. In- and out-patient based cardiology services are provided to the populations of north and mid Powys in Shrewsbury and Hereford, by the Shrewsbury and Telford Hospitals NHS Trust and the Wye Valley NHS Trust respectively. The population of south Powys receives its services from the Nevill Hall and Royal Gwent Hospitals (Aneurin Bevan University Health Board) and Morriston Hospital (Abertawe Bro Morgannwg University Health Board). In relation to consultant-led outreach provision into Powys, cardiology clinics are held twice a week at Brecon Hospital, provided by Aneurin Bevan Health Board and a new service will commence in Newtown in early 2015, provided from the Shrewsbury and Telford Hospitals NHS Trust. 24 hour tape ECG and echocardiography are available. Specialist Services Page 6 of 32 The Welsh Health Specialised Services Committee (WHSSC) commissions ambulance and specialist heart services (including services for patients with congenital heart disease) for the Powys population, on behalf of Powys teaching Health Board. In discharging this responsibility, WHSSC reports to the Board of the Health Board. Powys patients requiring tertiary level intervention for cardiovascular/heart disease may be treated in a number of specialist centres, including Stoke/Wolverhampton (north Powys), Birmingham (mid Powys) and Cardiff (south Powys). With reference to ambulance services provided by the Welsh Ambulance Services Trust, Powys teaching Health Board is working alongside other Welsh Health Boards in Wales to implement joint unscheduled care plans, through its Unscheduled Care Board. The performance of the ambulance service is reported at Board level in Powys teaching Health Board through its integrated performance report. Patient Support Groups There are no heart disease-specific patient support groups in Powys. The local strategy is to move away from disease-specific expert groups, as such an approach would not be sustainable or effective in Powys. Further work will be taken forwards under the Powys Long Term Conditions programme, recognising that patients often have multiple and complex needs which are more efficiently and effectively managed through an integrated approach. Summary of the Powys Heart Disease Needs Assessment The Heart Disease Delivery Plan requires each Local Health Board to carry out local population needs assessments to promote healthy hearts and treat heart disease, review their services in the light of that assessment, identify gaps between need and current provision and identify where service provision needs to change to meet demand. Background The Powys heart disease epidemiological needs assessment was completed to support development and delivery of the Powys Heart Disease Delivery Plan in December 2013. Led by Public Health Wales, the Powys needs assessment does not yet completely reflect the anticipated scope of the plan (for example, congenital and inherited cardiac conditions; arrhythmias). In line with other Health Boards, it is anticipated that this may be addressed in the future. In the meantime, the needs assessment has underpinned the local priorities articulated in the Heart Disease Delivery Plan for Powys. The full needs assessment is available as an accompanying document to the plan. In the needs assessment, the term “significant” is used to signify a difference which is statistically significant; likewise, terms such as “higher” and “lower” are only used when a difference is statistically significant. Page 7 of 32 Key Messages There is some evidence from the Welsh Health Survey that Powys is “healthier” than the rest of the population of Wales – but the % differences are small and based on self-reporting There is some evidence from the Welsh Health Survey that Powys adults have healthier lifestyles than other Welsh adults. However, this effect tends to become diluted with increasing age. Further, the absolute positions within Powys in relation to lifestyle behaviours leave very considerable room for improvement Levels of smoking in Powys are not significantly different from the rest of Wales; rates are improving only slowly, in line with the rest of Wales. Smoking Cessation Services are currently failing to achieve target performance in Powys There is significant, socioeconomically-determined variation in the levels of harm being caused by smoking in Powys. For example, smoking-attributable mortality rates in the adult population > 35 years are around 1.5x higher in the most deprived populations in Powys, compared to the most affluent Based on GP registrations, the crude prevalence of coronary heart disease in Powys is not significantly different to the rest of Wales. Given the age structure of the Powys population, this is perhaps surprising – a higher prevalence could have been expected. Adjusting for age, the prevalence of coronary heart disease in Powys becomes significantly lower than the rest of Wales. Taken together with the findings of the Welsh Health Survey, there may be under-recording of coronary heart disease in Powys GP practices (for both males and females). There is evidence that similar concerns may exist for hypertension and diabetes Based on QOF analysis, there are opportunities to improve the primary care management of hypertension and diabetes in Powys. For example, there is evidence that 1 in 10 patients with coronary heart disease do not have a blood pressure below 150/90, 1 in 5 patients have a cholesterol level greater than 5 mmol/L and 1 in 12 patients did not receive ‘flu immunisation in the previous season. In addition, the there is considerable variation between practices in relation to the management of coronary heart disease and its main risk factors In Powys, premature mortality rates from overall cardiovascular and coronary heart disease are both currently better than the Wales average. However, this comparative approach is undermined by the fact that Wales performs relatively poorly on these measures compared to other European countries Expert advice from Public Health Wales supported the use of premature mortality from coronary heart disease as a proxy for need. Using this approach, there is some high level evidence that the relatively low emergency admission and intervention (angiography; revascularisation) rates for coronary heart disease in the Powys population are in line with local need. However, there is also significant Page 8 of 32 anecdotal evidence within Powys that patients with coronary heart disease present late to primary care (including after acute events). In addition, the relationship within Wales between “rurality” and patterns of service utilisation for coronary heart disease appears not to be clear cut. The position requires further investigation to define levels of potentially undiagnosed and unmet need in relation to coronary heart disease in Powys Population Health Profile Powys is the most rural area in England and Wales and has a resident population of 132,976. There are a greater proportion of residents aged over 50 years in Powys compared with Wales. The projected population pyramid for Powys for 2033 shows a substantial growth in the number of people aged over 60 years, who will form a large proportion of the Powys population Ystradgynlais is the most deprived area in Powys and is among the worst 10% areas in Wales. St John (Brecon), Newtown South, Welshpool Castle, Newtown Central and Llandrindod East / Llandrindod West are in the worst 30% There are three localities in Powys, each with their own GP clusters, with 47% of the Powys population living in North Powys Whilst the population of Powys experiences better life expectancy at birth and tends to experience better health outcomes than the rest of Wales, local inequities remain. There are persistent differences in life expectancy, healthy life expectancy and disability free life expectancy between the most and the least deprived fifths of the population An important feature is that Powys adults report using health services less than adults across Wales for both primary and secondary care. Possible reasons for this include cultural issues, less “need” for services and/or that poor access to services deters uptake 7% of the Powys population (age standardised) reports having a heart condition, lower than any other health board area and lower than the Wales average (9%) Mortality from cardiovascular disease is higher in Wales than many other European countries. Mortality rates are higher in males and are strongly related to deprivation. In Powys, mortality rates for those aged under 75 years are significantly lower than Wales average rates Mortality from circulatory disease for all persons of all ages as well as for those aged under 75 years is also lower in Powys than Wales. In Powys there is a persistent difference in premature mortality from circulatory disease between those who are in the most and least deprived populations Premature mortality rates in Powys from coronary heart disease are significantly lower than for Wales The Promotion of Healthy Hearts Page 9 of 32 The prevalence of smoking in Powys is not significantly different to the rest of Wales. Smoking attributable mortality in Powys in those aged over 35 years has been declining since 2001/03 and has remained significantly below Wales. There are differences in smoking attributable mortality between the most and least deprived communities in Powys A higher proportion of Powys adults report eating five portions of fruit and vegetables a day compared with Wales. However, survey results for 11 to 16 year olds shows that a lower proportion of boys in Powys eat fruit or vegetables daily In Powys, self reported physical activity rates amongst adults and children are higher than Wales Obesity is a risk factor for coronary heart disease, as well as other significant diseases such as diabetes and hypertension. Self reported obesity rates amongst adults in Powys are significantly lower than Wales Results of the National Childhood Measurement Programme show that obesity rates in reception year pupils in Powys are higher than Wales A lower proportion of Powys adults report drinking above guidelines or binge drinking compared with Wales average. A higher proportion of boys aged 11-16 years in Powys report drinking alcohol at least once a week compared with Wales. Hospital admissions linked to alcohol are lower than other Health Boards The Role of Primary Care in the Management of Coronary Heart Disease The age standardised prevalence of coronary heart disease on GP registers is significantly lower in Powys than Wales. This could be an indication of a healthier population in Powys or under recording in GP practices. This is also the case for hypertension prevalence and diabetes prevalence A lower proportion of Powys residents with hypertension are given lifestyle advice when compared to the rest of Wales Diabetes management in GP practices is similar in Powys to the rest of Wales, except for one indicator relating to blood pressure management in patient with diabetes QOF data relating to the management of coronary heart disease shows that Powys is performing to similar levels as Wales There needs to be close working with GP practices to better understand where there is significant variation in QOF data between practices and to address areas where optimal clinical management is not being undertaken Fast and Effective Care For both angiography and revascularisation interventions, Powys has lower intervention rates than other Health Boards, with rates significantly below that of Wales. It is not yet possible to determine Page 10 of 32 whether these interventions rates are appropriate for the Powys population The limited nature of this data makes it difficult to draw further conclusions. Recommendations have been made for areas requiring further investigation Improving Information and Targeting Research The needs assessment does not yet provide a comprehensive picture of potentially unmet need in Powys. This section of the needs assessment highlights where further information and research would help to provide a more robust understanding of heart health needs in Powys Local Prevention Priorities Powys is more likely to have a higher burden of coronary heart disease in future due to its aging population, highlighting the need to have a focus on healthy aging To reduce smoking prevalence and reduce health inequalities there is a need to: o Target groups with highest smoking prevalence and target children and young people o Ensure smoking cessation services are accessible and effective o Optimise the work of GP practices through QOF to increase the proportion of patients with long term conditions who are given smoking cessation advice and referred to smoking cessation services o All contacts with healthcare staff should be an opportunity to prevent smoking and increase smoking cessation rates o Advocate for interventions that will have an impact at a population level e.g. smoke-free cars, tobacco plain packaging Increase fruit and vegetable consumption in adults and more specifically in children. This will be taken forward as part of the Powys Healthy Weights Strategy, based on a strong partnership approach Increase physical activity levels for people of all ages in Powys, again through the Powys Healthy Weight Strategy Through the work of the Childhood Obesity Group (currently established on a task and finish basis as a subgroup of the Powys Healthy Weights Steering Group) there should be focused partnership work to reduce levels of childhood overweight and obesity in Powys Reduce excess alcohol consumption by: o Better understanding the reasons for alcohol consumption in children, particularly boys o Having a partnership approach to tackling underage drinking o Advocating interventions that will have an impact at population level e.g. minimum unit pricing Optimise the promotion of healthy behaviours in the primary care setting e.g. increase the proportion of patients with long term conditions given lifestyle advice by GP practices as part of QOF Page 11 of 32 Work with communities to develop local engagement and ownership of health issues. Potential vehicles for achieving this in Powys include the development of Community Champions and improving local delivery through the neighbourhood management approach Local Delivery Priorities 7. Mapping of community service utilisation and effectiveness is needed to better understand pathways of care and obtain a more complete picture of heart health need in Powys. Early detection is a key component in the management of coronary heart disease. Further investigation is needed into rates of diagnosis of coronary heart disease in GP practices in Powys, as part of QOF Work with GP practices to optimise opportunities for secondary prevention e.g. optimising blood pressure or reducing cholesterol levels in patients with coronary heart disease Further work to explore the relatively low rates of angiography and revascularisation is needed, including through stakeholder discussion At present, intervention rates are compared with Wales’ average. However, this approach should be reviewed to explore the utility of comparisons with other countries which experience better cardiovascular disease outcomes than Wales Participation in Clinical Audit At present Powys teaching Health Board does not routinely undertake audit in relation to the implementation of the HDDP as this is undertaken by service provider organisations. However, work is underway within the Health Board to look at audit measures to support the implementation of the Powys HDDP and Powys teaching Health Board’s contribution to National Clinical Audit. As no audits were undertaken in the previous 12 months there are no priorities to report. However, as stated above this in being reviewed locally. 8. Development of Powys Health Board Local Delivery Plan for Heart Disease In order to refresh the Powys HDDP, a 6 months interim assessment of progress against the plan was undertaken. This is to be presented to the Executive Team within Powys teaching Health Board in January 2015, along with a draft refresh of the Powys HDDP and recommendations for further ensuring delivery of the plan. Powys teaching Health Board will then agree actions to be undertaken during the period 2014-2016 and expected outcomes. In addition to this the HDDP was updated to reflect the National priorities as agreed by the Heart Disease Implementation Group. Page 12 of 32 9. Our Priorities Following the completion of our review of progress made over the last 12 months we have now reviewed and assessed our delivery plan priorities and actions for the coming 12 months. Our action plan for heart disease includes actions against each of the priorities within the Welsh Government’s Heart Disease Delivery Plan (2013) and actions to implement the Cardiac Disease NSF and the Welsh Health Specialised Services Committee Review of Cardiac Services. Promotion of healthy hearts The priorities for 2013 – 16 are: 1. Work with a broad range of partners (including Local Service Boards and the third sector) to: Raise awareness of healthy living Signpost existing sources of information, advice and support relating to lifestyle change6 Develop and deliver local strategies and services to tackle underlying determinants of health inequality and risk factors for coronary heart disease Target resources in population areas of high risk (such as areas of deprivation) and areas of high impact (including early intervention actions with children to tackle prevention from outset of life) 2. Support and facilitate GPs, practice nurses and community pharmacists to proactively: Use every opportunity in primary care to promote healthy lifestyle choices and smoking cessation Ensure consistent provision of testing and treatment for risk factors such as high blood pressure and cholesterol Locally determined priorities are detailed in the Plan Timely detection of heart disease The priorities for 2013 – 16 are: 1. Identify and implement ways of raising public awareness of the symptoms of heart disease and the importance of seeking urgent medical advice and raise awareness of when to ring 999, seek advice from NHS Direct and when to contact their GP 6 Including, for example, Stop Smoking Wales, Fresh Start Wales, Change 4 Wales Page 13 of 32 2. Provide GPs with timely access to diagnostic testing and procedures for heart disease, increasing direct access to testing (at the point of care or from a central laboratory), without need for secondary referral, where appropriate 3. Provide rapid access services to meet GP and patient need 4. Provide GPs with timely access to specialist cardiology advice through telephone and email, speeding diagnosis for people who may not need referral to a clinic 5. Ensure adequate access to cardiac catheter laboratories, matched to population need 6. Raise symptom awareness of GPs and ensure through audit that people are referred to secondary and tertiary care in line with national guidance and referral protocols and pathways agreed by the cardiac networks 7. Provide specialist cardiology advice within 24 hours for those admitted to hospital with suspected heart disease - reorganising delivery of services to achieve this where necessary 8. Ensure effective collaboration between the All Wales Medical Genetics Service, Cardiac Networks, Hospital Lipid Clinics and GPs to use the Familial Hypercholesterolaemia Cascade Testing service to identify and treat individuals with Familial Hypercholesterolaemia and reduce the high risk of this group developing early onset heart disease 9. Ensure effective use of arrhythmia specialists and the All Wales Medical Genetics Service to ensure patients with inherited heart conditions have appropriate advice and testing and that specialist advice is provided to interpret the results Locally determined priorities are detailed in the Plan Fast and effective care The priorities for 2013 – 16 are: 1. Organise services to ensure people admitted because of diagnosis with a heart disease are assessed by a consultant cardiologist7, within 24 hours of admission to hospital 2. Start definitive treatment in a timely manner, with a focus on driving down waiting times and meeting clinical need. As a minimum treatment must start in line with the 26 week Referral to Treatment waiting times target for cardiac disease 3. Deliver prompt and equitable access to appropriate interventions, including new diagnostic procedures, technologies, treatment and techniques, in line with the latest evidence and guidance and with evidence based policies and priorities agreed by NHS Wales 7 A consultant cardiologist is someone on the General Medic register with a Certificate of Completion of Training (CCT) or Certificate of Completion of Specialist Training (CCST) in cardiovascular medicine or cardiology, who is employed as a consultant, spends the majority of their direct clinical care programmed activities caring for patients with heart disease and who undertakes regular continuing professional development of relevance to the care of patients with heart disease. Page 14 of 32 4. Ensure all complex surgery is undertaken with peri-operative care standards as in the ERAS project 5. Use the 1000 Lives Plus Programme to implement improvements to services for people with acute coronary syndrome, heart failure, atrial fibrillation and in need of anti-coagulation 6. Manage effective transition to quaternary services in England where needed 7. Coordinate effective discharge and timely repatriation of patients to local hospitals as soon as clinically appropriate following treatment in line with discharge plans and the All Wales Repatriation Policy 8. For patients who need it, ensure effective transition to appropriate palliative and end of life care, in line with the Delivering End of Life Care Plan 9. Develop an NHS Wales policy on Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions, ensuring that this always respects individual patient wishes 10. Review provision of defibrillators in public places and community first responders, within LHB areas, ensuring - in liaison with the WAST and the British Heart Foundation - that there is adequate provision and training and an effective first responder in place Locally determined priorities are detailed in the Plan Living with heart disease The priorities for 2013 – 16 are: 1. Plan and deliver services to meet the on-going needs of people with heart disease as locally as possible to their home and in a manner designed to support self management and independent living. This should include as appropriate: Evidence based follow-up in the community where possible Drug and device management Cardiac rehabilitation (including psychological management and exercise) Exercise programmes (such as the National Exercise Referral Programme) Guidance on healthy lifestyle and self-care to minimise further ill health 2. Assess the clinical and relevant non-clinical needs of people with a diagnosis of a long term heart disease and – in liaison with patients (and where appropriate family/carers) - record relevant clinical and non-clinical needs and wishes as the basis of implementing care in a care plan. This should include adults with congenital heart disease. The care plan should include information on what the diagnosis means for the patient, what to look out for and which service to access should problems occur; it should be reviewed at appropriate points along the pathway 3. Make arrangements to ensure that information in the care plan or GP letter is available both to the patient and recorded on clinical information Page 15 of 32 systems - and is accessible to others who have clinical responsibility for the patient, including out-of-hours GP services, on a 24/7 basis 4. Provide access to expert patient and carer programmes when required 5. Work proactively with third sector services and provide effective signposting to information and support, enabling patients to easily access support services Locally determined priorities are detailed in the Plan Improving Information The priorities for 2013 – 16 are: 1. Ensure IT infrastructure supports effective sharing of clinical records/care plans 2. Put effective mechanisms in place for seeking and using patients’ views about their experience of heart services 3. Monitor and record performance against the Cardiac Disease National Service Framework and through annual self-assessment against the Quality Requirements and use the results to inform and improve service planning and delivery 4. Ensure full (100%) participation in mandatory national clinical audits, delivering significant improvements on current low participation rates - to support service improvement and support medical revalidation of clinicians – and ensure that findings are acted on 5. Participate in and act on the outcome of peer review 6. Publish regular and easy to understand information about the effectiveness of heart services Locally determined priorities are detailed in the Plan Targeting Research The priorities for 2013 – 16 are: 1. Support and encourage protected research time for clinically active staff (in primary as well as secondary and tertiary care) 2. Build on and extend academic training schemes to develop a highly skilled workforce 3. Promote collaboration with key research initiatives such as CVRG-C and HBRU 4. Promote public health research, for example to identify the best ways of working with those who are most disadvantaged or to demonstrate how services meet individual and population needs 5. Invest in accurate collection of key clinical data in a format that can be incorporated into the SAIL (Secure Anonymised Information Linkage) database for population-level health and social care research including focus on epidemiology, impact of interventions on outcomes, clinical trial scoping and service delivery modelling and assessment Page 16 of 32 6. Collaborate effectively with universities and businesses in Wales to enable a speedier introduction of new evidence-based and cost-effective technology into the NHS Locally determined priorities are detailed in the Plan The Heart Disease Implementation Group has agreed a small number of priorities for the 12 months that will be addressed at a national level. These are: 1. Developing a consistent model for the delivery of cardiovascular risk assessment 2. Delivering the cardiac waiting time target through more effective pathways 3. Developing and piloting component or differential waiting time targets 4. Consider new workforce models of delivery that release capacity 5. Improving participation and case ascertainment in National Clinical Audit A paper outlining the current position of the HDDP and the requirement to focus on the above priorities is due to be presented to the Board in February 2015 when PtHB will report on how it plans to address the agreed priorities going forward. 10. Performance Measures/Management The Welsh Government’s Heart Disease Delivery Plan (2013) contained an outline description of the national metrics that LHBs and other organisations will publish: Outcome indicators which will demonstrate success in delivering positive changes in outcome for the population of Wales. NHS assurance measures which will quantify an organisation’s progress with implementing key areas of the delivery plan. Progress with these outcome indicators will form the basis of our annual report on heart disease. Page 17 of 32 Powys Heart Disease Delivery Plan Action Plan: 2013 - 2016 Theme 1: The Promotion of Healthy Hearts Priority Actions To further consolidate local partnership working to deliver the series of specific priorities in the national plan Raise awareness of healthy living, including through rollout of the One Powys Plan with Powys County Council Signposting of information, advice and support for lifestyle change Expected outcome Risks to Delivery Increase in referrals to lifestyle support services and Stop Smoking Wales Lack of public health specialist capacity in the Powys PH team Development of a health inequalities action plan for Powys Levels of unmet need, coupled with financial position of the Health Board Timescales / Milestones Lead By April 2015 DPH Promotion of smoking cessation services (Pharmacy, SSW). Smoking cessation pathways for maternity and pre-op being developed. SSW currently reviewing the service across Wales. Rolling out MECC within the HB from April 2015. Health Inequalities Action Plan is being developed. As above DPH Smoking cessation services are being promoted to GPs/Pharmacy. Rolling out MECC within the HB from April 2015. Working with SSW nationally to develop an action plan to increase accessibility and referrals to SSW. Powys Tobacco Action Plan has been developed More effective targeting of resources according to need Develop local action plans for health inequalities and risk factors for coronary heart disease To support and facilitate GPs, practice nurses and community pharmacists to deliver a proactive approach Target resources at areas of high risk and high impact (including CYP) Healthy lifestyle choices including smoking cessation to be actively promoted in primary care Roll out and further development of Making Every Contact Count in Powys, in line with the PtHB 3 Year Plan transformation programme As above plus Improved rates of smoking cessation Powys THB staff trained in and delivering brief intervention As above Additional Information Page 23 of 32 Improve the delivery of Stop Smoking Wales in Powys LOCAL To support development of the 50+ Health Checks Programme approach in Powys Address the other primary preventive opportunities identified in the PtHB HDDP Needs Assessment Await evaluation of pilot phase (elsewhere in Wales) and localise to Powys, in preparation for national rollout Implement locally as part of national rollout of “Add to Your Life” from 4/14 Target groups with highest smoking prevalence and target children and young people Ensure smoking cessation services are accessible and effective Optimise the work of GP practices through QOF to increase the proportion of patients with long term conditions who are supported through healthy lifestyle advice (including smoking cessation) an onward referral where appropriate All contacts with healthcare staff to be used as an opportunity to prevent smoking and increase smoking cessation rates Advocate interventions that will have an impact at Roll out of “Add to Your Life” in Powys Lack of senior specialist public health capacity in Powys By April 2015 (subject to national timetable) DPH By April 2015 then ongoing DPH Implications of a rural IT infrastructure and rural population for an on-line programme Improved position and trend across a range of population health outcome measures (through Three Year Plan process) Local performance of Stop Smoking Wales Lack of senior specialist public health capacity in Powys Competing priorities faced by frontline staff Targeted work on maternity, smoke free homes, focus on Stoptober for the most deprived areas of Powys. Healthy Lifestyle LES linked to MECC. Making Every Contact Count roll out from April 2015. Targeted approach to ABI is being delivered and links to MECC made. Neighbourhood management - community research undertaken to support the needs assessment and develop action plan (Newtown) CEON Community Engagement Officers Network. Healthy Weights action plan in place and reviewed quarterly by Healthy Weights Steering group (chaired by DPH). Fruit and vegetable consumption covered in all AC courses delivered by the Public Health Dietitians. Page 24 of 32 a population level (e.g. smokefree cars, tobacco plain packaging) Through the Powys Healthy Weights Strategy: increase fruit and vegetable consumption and levels of physical activity (all ages) Reduce excess alcohol consumption through a targeted approach To realise the opportunities identified in the PtHB HDDP Needs Assessment for enhanced identification and management of CHD and its risk factors in primary care (including variation between practices) Work with communities to develop local engagement and ownership of health issues Findings of the PtHB HDDP Needs Assessment to be addressed through the annual planning and performance review mechanisms for primary care Improved performance on a specified range of QOF measures Lack of capacity in primary care team As per current primary care assurance and review processes Medical Director Page 25 of 32 Theme 2: Timely Detection of Heart Disease Priority Actions To identify and implement ways of raising public awareness of the symptoms of heart disease and the importance of seeking urgent medical advice and raise awareness of when to ring 999, seek advice from NHS Direct and when to contact their GP Development of local communication and engagement plan to support delivery of the HDDP in Powys, encompassing a public education campaign about the symptoms of heart disease (as part of wider approach to USC) Development of PtHB locality commissioning plans To provide GPs with timely access to diagnostic testing and procedures for heart disease, increasing direct access to testing (at the point of care or from a central laboratory), without need for secondary referral, where appropriate To provide rapid access services to meet GP and patient need To provide GPs with timely access to specialist cardiology advice through telephone and email, speeding diagnosis for people who may not need referral to a clinic To ensure adequate access to cardiac catheter laboratories, matched to Expected outcome Risks to Delivery Timescales / Milestones Lead Improved levels of understanding and awareness of symptoms of heart disease in local communities Lack of local comms capacity to design, and implement and evaluate an ongoing proactive scheme of this nature Revised timescale to be agreed PtHB Urgent Care lead Services commissioned Organisational capacity System to be in place for 2015/16 contract year PtHB locality lead commissioners Additional Information Complexity of provider arrangements Financial position of PtHB As above As above As above As above PtHB locality lead commissioners As above As above As above As above PtHB locality lead commissioners Development of PtHB locality commissioning plans (through Services commissioned Organisational capacity System to be in place for 2015/16 contract year PtHB locality lead commissioners Page 26 of 32 population need To raise symptom awareness of GPs and ensure through audit that people are referred to secondary and tertiary care in line with national guidance and referral protocols and pathways agreed by the cardiac networks To provide specialist cardiology advice within 24 hours for those admitted to hospital with suspected heart disease reorganising delivery of services to achieve this where necessary To ensure effective collaboration between the All Wales Medical Genetics Service, Cardiac Networks, Hospital Lipid Clinics and GPs to use the Familial Hypercholesterolaemia Cascade Testing service to identify and treat individuals with Familial Hypercholesterolaemia and reduce the high risk of this group developing early onset heart disease To ensure effective use of arrhythmia specialists and the All Wales Medical WHSSC) Complexity of provider arrangements Establish appropriate educational and clinical audit programmes Improved levels of knowledge and referral practice amongst Powys GPs Development of PtHB locality commissioning plans Services commissioned Financial position of PtHB Organisational capacity As above Medical Director As above PtHB locality lead commissioners Financial position of PtHB Any requirement for additional investment to repatriate the activity to Powys Revised timescale to be agreed DPH (with locality general manager mid-Powys) Via WHSSC Via WHSSC Via WHSSC Competing demands on GP time Organisational capacity Complexity of provider arrangements Complete work in hand to deliver an outreach OP FH service for Powys in Llandrindod, as part of the wider Powys repatriation programme Model implemented and pathways established Via WHSSC (all Wales action plan) Via WHSSC Page 27 of 32 Genetics Service to ensure patients with inherited heart conditions have appropriate advice and testing and that specialist advice is provided to interpret the results LOCAL Powys tHB to be an active participant in the programme of work (agreed at the SW Cardiac Network HDDP Implementation Group) to examine access, waiting time variation and service configuration issues (the Network and LHBs, though WHSSC) To ensure Powys participation in the South Wales Cardiac Network Task and Finish Group established to develop/recommend a cardiovascular risk assessment tool for Wales, to ensure that local opportunities are realised To be confirmed by SWCN To be confirmed by SWCN Initially via CEO then PtHB locality lead commissioners Timescale to be confirmed DPH Action plan and T&F to be established at national level Page 28 of 32 Theme 3: Fast and Effective Care Priority To organise services to ensure people admitted because of diagnosis with a heart disease are assessed by a consultant cardiologist8, within 24 hours of admission to hospital To start definitive treatment in a timely manner, with a focus on driving down waiting times and meeting clinical need. As a minimum treatment must start in line with the 26 week Referral to Treatment waiting times target for cardiac disease To deliver prompt and equitable access to appropriate interventions, including new diagnostic procedures, technologies, treatment and techniques, in line with the latest evidence and guidance and with Actions Development of PtHB locality commissioning plans Expected outcome Risks to Delivery Services commissioned Organisational capacity Complexity of provider arrangements Timescales / Milestones Lead System to be in place for 2015/16 contract year PtHB locality lead commissioners Additional Information Financial position of PtHB As above As above As above As above PtHB locality lead commissioners As above As above As above As above PtHB locality lead commissioners A consultant cardiologist is someone on the General Medical Council’s specialist register with a Certificate of Completion of Training (CCT) or Certificate of Completion of Specialist Training (CCST) in cardiovascular medicine or cardiology, who is employed as a consultant, spends the majority of their direct clinical care programmed activities caring for patients with heart disease and who undertakes regular continuing professional development of relevance to the care of patients with heart disease. Page 29 of 32 8 evidence based policies and priorities agreed by NHS Wales To ensure all complex surgery is undertaken with peri-operative care standards as in the ERAS project To use the 1000 Lives Plus Programme to implement improvements to services for people with acute coronary syndrome, heart failure, atrial fibrillation and in need of anti-coagulation To manage effective transition to quaternary services in England where needed To coordinate effective discharge and timely repatriation of patients to local hospitals as soon as clinically appropriate following treatment in line with discharge plans and the All Wales Repatriation Policy For patients who need it, to ensure effective transition to appropriate palliative and end of life care, in line with the Delivering End of Life Care Plan To review provision of defibrillators in public places and community Via WHSSC Via WHSSC Via WHSSC Via WHSSC Via WHSSC Development of PtHB locality commissioning plans Services commissioned Organisational capacity System to be in place for 2015/16 contract year PtHB locality lead commissioners Complexity of provider arrangements Financial position of PtHB Via WHSSC Via WHSSC Via WHSSC Via WHSSC Via WHSSC Development of PtHB locality commissioning plans Services commissioned Organisational capacity System to be in place for 2015/16 contract year PtHB locality lead commissioners System to be in place for 2015/16 contract year PtHB locality lead commissioners Revised timescale to be agreed TBD from 2014/15 Complexity of provider arrangements Financial position of PtHB Development of PtHB locality commissioning plans For review in Powys in collaboration with WAST and in light of Services commissioned Organisational capacity Complexity of provider arrangements TBD from 2014/15 Financial position of PtHB TBD from 2014/15 Page 30 of 32 first responders, within LHB areas, ensuring in liaison with the WAST and the British Heart Foundation - that there is adequate provision and training and an effective first responder in place LOCAL To improve reporting arrangements from WHSSC to PtHB including in relation to the impact and outcome of the Cardiac Services Review for the Powys population the 2014 WAST “Cardiac Arrest Survival Plan” (through revised commissioning arrangements from 2014/15) Establish improved accountability and reporting arrangements from WHSSC to Board of PtHB on cardiac issues Local progress to be reported through the HDDP Annual Review Additional investment required to implement the recommendations of the Review Revised timescale to be agreed Director of Planning Issue likely to be included in report of PtHB review of its commissioning arrangements Workforce and OD issues Page 31 of 32 Theme 4: Living with Heart Disease Priority To plan and deliver services to meet the on-going needs of people with heart disease as locally as possible to their home and in a manner designed to support self management and independent living. This should include as appropriate: Evidence based followup in the community where possible Drug and device management Cardiac rehabilitation (including psychological management and exercise) Exercise programmes (such as the National Exercise Referral Programme) Guidance on healthy lifestyle and self-care to minimise further ill health To assess the clinical and relevant non-clinical needs of people with a diagnosis of a long term heart disease and – in liaison with patients (and where appropriate family/carers) - record relevant Actions Expected outcome Ensure the needs of patients with chronic heart disease (including secondary prevention) are adequately reflected in the Powys long term conditions and carers programmes Ongoing needs of patients with heart disease are met through the Powys long term conditions programme As above: through the long term conditions programme (care plans already in the draft model) Ensure Powys engagement in the As above Risks to Delivery Inability to shift the pattern of financial investment in Powys to primary and community-based services Timescales / Milestones Lead System to be in place for 2015/16 contract year PtHB locality lead commissioners As above PtHB locality lead commissioners Additional Information Financial position of PtHB As above Page 32 of 32 clinical and non-clinical needs and wishes as the basis of implementing care in a care plan. This should include adults with congenital heart disease. The care plan should include information on what the diagnosis means for the patient, what to look out for and which service to access should problems occur; it should be reviewed at appropriate points along the pathway Make arrangements to ensure that information in the care plan or GP letter is available both to the patient and recorded on clinical information systems and is accessible to others who have clinical responsibility for the patient, including out-ofhours GP services, on a 24/7 basis To provide access to expert patient and carer programmes when required To work proactively with third sector services and provide effective signposting to information and support, enabling patients to easily access support services LOCAL Nurse-led cardiac rehabilitation programme of work established by the National HDDP Implementation Group to develop the care plan approach across Wales Design and implement the IS and IT solutions Information available and accessible Poor IT infrastructure in some community services System to be in place for 2015/16 contract year PtHB information and IT leads PtHB locality lead commissioners PtHB locality lead commissioners Organisational capacity Establish work programme As above To develop a local response to the findings of the Review of Cardiac Rehabilitation in South Wales Programme established as part of LTC programme As above Organisational capacity As above As above As above Findings of review addressed as part of local priority setting Any additional investment requirements Revised timescale to be agreed Organisational capacity PtHB locality lead nurse(s) Each locality continuing to support nurse led cardiac rehabilitation. Demand for the programme has remained and there Page 33 of 32 Nurse-led management of heart failure To develop a local response to the findings of the Review of Heart Failure Nurse Specialist Services in South Wales Findings of review addressed as part of local priority setting Any additional investment requirements Organisational capacity Revised timescale to be agreed PtHB locality lead nurses(s) has been an observed increase in the demand for clinics. This has manifested differently for each locality and the team are responsive and flexible in their approach, focusing on what is required at any particular time for their locality. For the South Locality the Care Planning Group is to establish a Task & Finish Group to look at specialist nurse staffing and current services to Brecon Hospital. GPs have marked it as a priority in their cluster plan. Work is underway with one particular GP who is using risk stratification software in highlighting heart failure patients. This information is being used to develop a nurse led clinic which will assist in seeing the right patient at the right time. Page 34 of 32 Theme 5: Improving Information Priority To ensure IT infrastructure supports effective sharing of clinical records/care plans To put effective mechanisms in place for seeking and using patients’ views about their experience of heart services To monitor and record performance against the Cardiac Disease National Service Framework and through annual self-assessment against the quality requirements and use the results to inform and improve service planning and delivery To ensure full (100%) participation in mandatory national clinical audits, delivering significant improvements on current low participation rates - to support Actions Expected outcome Local engagement in the task and finish group being established through the SWCN to produce, with NWIS, a vision for integrating IT systems (linking in with research data) Establish mechanisms through existing patient engagement arrangements at PtHB locality level Integrated information system across primary care and community services Agree the role of SWCN in supporting PtHB in its assurance responsibilities as a commissioner of heart services Assurance completed (encompassing all provider organisations) Improved coordination of care Patient views/experience are more influential in the commissioning process Risks to Delivery Availability of capital and revenue Timescales / Milestones Lead Implementation from 2015 at Wales level PtHB information lead Revised timescale to be confirmed PtHB patient engagement lead As above PtHB performance and quality leads By April 2015 PtHB clinical audit lead Additional Information No IT system for community nursing services Competing priorities for patient engagement work Lack of organisational capacity Complexity of provider arrangements Establish internal processes Await SWCN review of Health Board input to the national clinical audits As above As above Page 35 of 32 service improvement and support medical revalidation of clinicians – and ensure that findings are acted on To participate in and act on the outcome of peer review To publish regular and easy to understand information about the effectiveness of heart services LOCAL To investigate and address the current gaps in information and analysis relating to current services, as identified in the PtHB HDDP Needs Assessment (including registration rates for coronary heart disease in GP practices in Powys) Peer review to be established for PtHB To be established as part of the annual report To agree and implement a programme of work with PHW More effective identification and sharing of good practice Information published Comparable peer for Powys not realistic within Wales Availability of Powysspecific effectiveness intelligence from all provider organisations By April 2015 Intelligence issues/gaps identified in the HDDP needs assessment fully identified and addressed for Powys Lack of local PH intelligence capacity Revised timescale to be confirmed Revised timescale be confirmed SWCN to PtHB performance lead DPH Competing priorities in PHW Page 36 of 32 Theme 6: Targeting Research Priority LOCAL PtHB heart research: establish baseline position Progress and complete current research Identify public health research opportunities Actions Expected outcome Risks to Delivery Timescales / Milestones Lead Additional Information SWCN audit of current research complete. SWCN in the process of setting up a group to look at next steps The BAFTA study has now closed; no Powys patients were recruited To participate in the SWCN audit of current HB research activity, budgets and funding Baseline established Lack of local capacity to contribute to the audit Revised timescale to be agreed Medical Director (through PtHB research lead) Complete local participation in the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) follow-up study (a longterm follow-up study of an earlier RCT examining warfarin versus aspirin for stroke prevention in the management of atrial fibrillation in an elderly (> 75) primary care population Develop links with PHW research leads Powys participation in the BAFTA study successfully concluded Inadequate local links established with the research lead in Birmingham Closed Medical Director (through PtHB research lead) Local research opportunities better understood and realised Organisational capacity Revised timescale to be agreed DPH Page 37 of 32