Primary Care Measures for Wales Performance Report

Primary Care Measures for Wales Performance Report Situation This report sets out the all Wales Primary Care phase 1 measures agreed via the Directors of Primary, Community and Mental Health services. The measures provide Hywel Dda University Health Board assurance in terms of performance against key primary care and population health measures, as well as identify opportunities for quality improvement, in particular through addressing issues of cluster variation and provides more detail on actions being taken to improve performance in areas of concern. Background An initial set of primary care measures were developed, led by Public Health Wales 1000Lives, with strong stakeholder input. These measures were mainly process measures and based on areas where data currently exists such as the GMS contract Quality and Outcomes Framework, Public Health screening, flu reporting etc. These phase 1 measures approved by the Directors of Primary, Community and Mental Health are reported in this report as a proof of concept. Work by the all Wales Primary Care measures group continues on the phase 2 measures. Assessment 1.1 Staying Healthy Screening Screening is a process of identifying apparently healthy people who may be at increased risk of a disease or condition. They can then be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition. Screening programmes allow for the early detection and treatment of potential health problems. The primary care measures related to screening focus on uptake for three areas bowel, breast and cervical screening. 1.11Bowel Screening Hywel Dda s uptake against the target of 60% was 51.7%, this the 2 nd highest uptake across Wales. 1

When broken down to a cluster level, there is a range of uptake between 49.03% in Llanelli and 53.63% in Aman/Gwendraeth. The link with deprivation is well described: the most deprived communities show the lowest uptake of screening Graph 1b - Bowel Screening Coverage (within 2.5 years) by Deprivation Quintile and Health Board of Residence, as at 1 st October 20 2

Full detail of the Screening Programme can be found in the annual statistical report from Bowel Screening Wales 20/ BSW Annual Statistical Report 201 What actions are we taking? Hywel Dda Public Health Directorate is working with Clusters to carry out work to increase the uptake of Bowel Screening invitations (and to promote all screening programmes) through a Cluster organised training and advocacy programme through Third Sector service providers and the three County Voluntary Councils. This work will be carried out during Q3/4 of 20/16 with a full evaluation report submitted to Clusters in April 2017. 1.12 Breast Screening Breast Screening is targeted at women: 50 70 years; every 3 years (over 70s can request) with a minimum standard of 70%. The latest reported figures for Hywel Dda are as follows: Hywel Dda s uptake against the target of 80% was 74.5%, this is the highest uptake across Wales. When broken down to a cluster level, there is a range of uptake from 72.% in Llanelli to 76.37% in North Pembrokeshire. 3

How do we compare with our peers? Hywel Dda area has the highest coverage of Health Board area. Graph 1c: Breast screening coverage %, women aged 53-70, by Health Board of residence, 2013-20 100.0 90.0 80.0 70.0 72.7 73.2 66.7 72.1 71.2 73.3 70.7 71.2 60.0 50.0 40.0 at 31/03/13 at 31/03/ at 31/03/ 30.0 20.0 10.0 0.0 Abertawe Bro Aneurin Bevan Betsi Cadwaladr Cardiff & Vale Morgannwg Uni University University University Cwm Taf University Hywel Dda University Powys Teaching Wales Full detail of the Screening Programme can be found in the annual statistical report from Breast Test Wales 20/ BTW Programme Performance Report 2 What actions are we taking? Hywel Dda Public Health Directorate is working with Clusters to carry out work to increase the uptake of Bowel Screening invitations (and to promote all screening programmes) through a Cluster organised training and advocacy programme through Third Sector service providers and the three County Voluntary Councils. This work will be carried out during Q3/4 of 20/16 with a full evaluation report submitted to Clusters in April 2017 1.13 Cervical Screening Cervical Screening is targeted at Women: 25-50 years: every 3 years and 50-64 years: every 5 years; with a target of 80%. The latest reported figures for Hywel Dda are as follows: 4

When broken down to a cluster level, How do we compare with our peers? Hywel Dda area has the lowest coverage of Health Board areas. What actions are we taking? Hywel Dda Public Health Directorate is working with Clusters to carry out work to increase the uptake of Bowel Screening invitations (and to promote all screening programmes) through a Cluster organised training and advocacy programme through Third Sector service providers and the three County Voluntary Councils. This work will be carried out during Q3/4 of 20/16 with a full evaluation report submitted to Clusters in April 2017 Full detail of the Screening Programme can be found in the annual statistical report from Cervical Screening Wales 20/ CSW Annual Statistical Report 201 5

1.2 Staying Healthy Immunisation The flu immunisation uptake data is submitted by general practices through Audit+. The data is updated on a weekly basis throughout the seasonal flu period. Guidance on use and interpretation of the flu uptake figures are available on the PHW website. 1.21 Influenza Population How do we compare with our peers? Where are we and are we on target? Performance was uneven across the UHB area. Overall, we did not reach the target for our community cohorts, although some GP practices achieved over 75% uptake rates in their localities. Flu A and B was circulating during February and March 2016 and had some impact on community and acute services. What are the challenges? Concerns exist in the community in respect of vaccine efficacy that will need to be challenged. Alongside this, a mild winter and the late onset of active influenza cases in the community has created a view that the vaccine is not required. With health care staff, more active flu champions are required in order to deliver workplace vaccinations to peers. 6

What actions are we taking? What is being done? The Imms & Vaccs team has conducted a research project with Ceredigion County Council and third sector partners, to explore reasons why over 65 s in this area do not take up the offer of flu vaccination [Ceredigion being the lowest County in Wales in regards to over 65 s flu uptake]. The results of this research will inform the direction and content of future public awareness campaigns on influenza vaccination for the Hywel Dda area. When can we expect improvement and by how much? There will be a greater focus on working with primary care to increase uptake rates in the community for the forthcoming season. We are striving to improve our performance in line with the all Wales average for the 2016/17 season and have set a trajectory to increase vaccination uptake by 2%. Data will be analysed in March 2017 to assess success against this target. How does this impact on both patients and finances? Increased vaccination rates mean better protection for the population of Hywel Dda, especially our vulnerable cohorts. Increased flu vaccination uptake in staff groups will help to protect them and their patients from developing influenza. This in turn will reduce the winter pressures on primary and secondary care services. Financially this could reduce the need for agency or bank staff to cover staff sickness absence. 1.22 Pre-school Childhood Immunisation Immunisation uptake figures come from Public Health Wales COVER reports and are calculated using data from the National Community Child Health Database (NCCHD). The NCCHD contains data provided, on a quarterly basis, from individual Health Board Child Health Office databases. 7

How do we compare with our peers? In Comparison to other Health Board s in Wales, Hywel Dda UHB have one of the lowest rates in all childhood vaccinations, and this is a cause for concern for all involved in Childhood immunisation rates, with the Childhood immunisation Group leading on discussing ways of combating the downward trend of preschool boosters and 2 nd MMR for children 3-5 years old What are the main areas of risk? What actions are we taking? The Childhood immunisation group meet every quarter to discuss perfomance and operational standard and quality. Within the Group, all service areas are tasked on sharing best practice, promoting immunisation and reducing incidents or risks. We are looking at data cleansing exercises to make sure that the data from GP computer records tally with the details from Child Health database- on the denominator and ones that have been vaccinated. the Immunisation and Vaccination Coordinator updates all nurses and health care assistants on performance within the Health Board, cluster and directs the nurses to their GP data on the Vaccine Preventable Disease Programme intranet site. Discussions at the training sessions involve strategies to increase uptake and reasons why children and adults do not get themselves vaccinated. Understanding the narrative behind the data informs us of the patterns of behaviourvery often this narrative is given to us by our community staff, understanding the behaviour pattern will empower the Group to look at different ways of approaching the subject and long-term increase the protection available to children. 8

Percent 1.3 Staying Healthy Smoking Smoking is the greatest single cause of avoidable mortality in Wales. This indicator shows the percentage of patients aged years or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months, data taken from the 20/ QOF domain. Smoking is the greatest single cause of avoidable mortality in Wales. This indicator shows the percentage of patients aged years or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months, data taken from the 20/ QOF domain. In April 2013, Welsh Government set Health Boards a new Tier 1 performance indicator within the NHS Wales Delivery Framework 2013- and Future Plans (Welsh Government, 2013b) related to smoking cessation where: 5% of smokers make a quit attempt via smoking cessation services, with at least a 40% Carbon Monoxide (CO) validated quit rate at 4 weeks. In addition, reducing smoking prevalence is a key action in the Tobacco Control Action Plan for Wales (TCAP) (Welsh Government, 2012) which sets out the aim to decrease adult smoking prevalence rates in Wales to 20% by 2016 and 16% by 2020 Smoking prevalence in the population continues to decline, with the TCAP target for 2016 being achieved in Hywel Dda UHB (see Figure below). However, the UHB overall continues to under performance against the Welsh Government Tier 1 Target with 1.4% (n=934) of smokers being treated in 20- and 2.0% (n=1228) in 20-16. Smoking Prevalence in Hywel Dda University Health Board (2003/4-20/). Source: Welsh Health Survey 30 25 27 20 20% Target (2016) 16% Target (2020)) 20 18 10 5 0 2003/04 & 2004/05 2004/05 & 2005/06 2005/06-2007 2007&08 2008&09 2009&10 2010&11 2011&12 2012&13 2013& Hywel Dda Wales When analysed by GP cluster, differences in prevalence between and within clusters exists (See graph below). The Llanelli cluster has the highest smoking prevalence with a range of 18.2% to 27.2%. For Amman Gwendraeth there is a range in smoking prevalence from 16.5% in some of the more rural parts of the cluster to 23.4% in central Ammanford. Likewise for South Pembrokeshire some of the lowest rates of smoking prevalence are in the more rural parts of the cluster (13.0%) with the higher rates in Pembroke Dock, Milford Haven and Neyland (23.0%). 9

25 Smoking Prevalence by GP Cluster in Hywel Dda University Health Board (%) Source: Welsh Health Survey (2016) Prepared by: Hywel Dda Public Health Team 20 Wales (20.5%) HDdUHB (18.9%) 10 5 0 16.8 19.3 20.7 16.8 18.6 20.3 19.4 2T's Amman Gwendraeth Llanelli N. Ceredigion S. Ceredigion N. Pembrokeshire S. Pembrokeshire How do we compare with our peers? Hywel Dda UHB (18.9%) Smoking prevalence in HDdUHB remains below the Welsh average and is the second lowest in Wales. What actions are we taking? Over the last year the UHB has invested in smoking cessation services to ensure an equitable service for smokers wanting to quit is provided across the region. Services include: * The development of a Pharmacy Level 3 Smoking Cessation Scheme, development of a Hospital based smoking cessation service that not only provides support for in-patients but works with primary care to target those with chronic conditions, those waiting for elective surgery and pregnant women. In addition, GP Practice profiles have been developed by Hywel Dda Public Health Team (HdPHT) to ensure each practice has an understanding of smoking prevalence in their population and prudent referral pathways. 10

HDdPHT are also working with Stop Smoking Wales to: Pilot a telehealth smoking cessation service in Ceredigion to address issues around rurality. Support those practices in clusters with the highest smoking prevalence, specifically, Llanelli, Amman Gwendraeth and South Pembrokeshire to ensure specialist support is provided and targets are achieved. 2. Safe Care Prescribing (Cephalosporin and Quinolone) This indicator focuses on Cephalosporin and Quinolone items as a percentage of all Antibacterial items prescribed. Prescribing of antibiotics is monitored using a number of prescribing indicators looking at total volume of antibiotics prescribed as well as focusing on those antibacterials associated with C Diff infections with the intention to reduce inappropriate overall prescribing as well as restricting use of co-amoxiclav, quinolones and cephalosporins to specific indications. How do we compare with our peers? Hywel Dda has the third highest update in Wales. What actions are we taking? Hywel Dda University Health board currently prescribes cephalosporins at a rate of 6.46 items per 1000 patients against a target of 3.6. 11

Most clusters across the Health Board have decreased their rate of prescribing when comparing the latest quarter data to the same period last year. South Ceredigion (3.633) are the best performing cluster and are only marginally above the national target of 3.6 items per 1000 patients. The performance trend for each cluster is shown below: Below is a summary of Hywel Dda s position compared to other health boards: No health Board in Wales is currently attaining the target. Hywel Dda is currently 5 th out of the 7 welsh health boards, and needs to almost half its rate of prescribing of cephalopsrins to achieve the national target. Quinolones Hywel Dda University Health board currently prescribes quinolones at a rate of 3.87 items per 1000 patients against a target of 2.3. There is varying performance amongst the clusters in the health board. North Ceredigion are the lowest prescribers of quinolones, prescribing 2.743 items per 1000 patients. The performance trend for each cluster is shown below: 12

Below is a summary of Hywel Dda s position compared to other health boards: No health Board in Wales is currently attaining this target. Hywel Dda is currently 5 th out of the 7 welsh health boards. Decreasing cephalosporin and quinolone prescribing is treated as a priority for the health board. High levels of prescribing of antibiotics and in particular cephalosporin and quinolones increases the risk of antibiotic resistance developing and increases the C.difficile cases. To address this, the health board is implementing a number of strategies: A suggested GMS action for each practice to review the use of prophylactic antibiotics. National prescribing indicators are discussed with prescribing lead G.P s on a quarterly basis. September 2016 prescribing leads meetings have/will focus on antibiotics, with presentations and discussion with the antibiotic pharmacist from the locality. Community Pharmacy and G.P practice antibiotic campaign is planned for November 2016 Promoting the Hywel Dda antibiotic app in primary care. 3. Effective Care Dying well % of patients dying in usual place of residence and palliative care prevalence There are two indicators: palliative care prevalence using the GMS palliative care registers, and the % of patients dying in their usual place of residence. HD Palliative Care Prevalence across years Palliative Care Prevalence 20-16 0.40% 0.6% 0.35% 0.5% 0.4% 0.30% 0.3% 0.25% 0.2% 0.20% 0.% 2010-11 2011-12 2012-13 2013-20- 20-16 0.1% 0.0% 2T AG LL NC SC&T NP SP CA CE PE HDUHB 13

4. Timely Care - Emergency admissions for chronic conditions The emergency admissions data is for the basket of eight chronic conditions: Alzheimers, Atrial Fibrillation, Cardiovascular, CVA, Diabetes, Musculoskeletal, Neurological and Respiratory. The graph below demonstrates the level of information available at an All Wales and Health Board level. This information would be more meaningful if available as a rate of admission per 1000 registered patients as the crude figures do not differentiate between the size or demography of each Health Board. On a very basic level, Hywel Dda is the 5 th largest Health Board in Wales and therefore it could be predicted that it should have the 5 th largest rates of admissions. Of particular note are : Alzheimers, Respiratory and Musculoskeletal where the Health Board have the lowest admission rates in 20-16. Atrial Fibrillation where the Health Board as the second highest admission rate in 2016/16. This information is not currently available at a cluster level. 5. Timely Care Access (% of GP Practices appointments at least 2 nights per week, % GP Practices open hours during core hours, Population accessing NHS primary dental care) These access indicator looks at GP practices offering appointments between 5pm and 6.30pm at least 2 nights per week and the % of GP practices open during daily core hours or within one hour of the daily core hours Monday to Friday. Percentage of Practices open within 1 hour of daily core hours as at November 20

Local monitoring data 72% 70% 68% 66% 64% 62% 60% 58% No v- 13 Hywel Dda GP Practices with doors open within 1 hours of daily core opening, 5 days a week Ja n- M ar- M ay- J ul- Se p- No v- Ja n- M ar- M ay- J ul- Se p- No v- Ja n- 16 M ar- 16 Percentage of practices offering appointments at any time between 17:00 and 18:30 at least 2 days per week as at November 20 Local monitoring data

102% Hywel Dda GP Practices offering appointments after 5pm on at least 2 days a week 100% 98% 96% 94% 92% 90% No v- 13 Ja n- M ar- M ay- J ul- Se p- No v- Ja n- M ar- M ay- J ul- Se p- No v- Ja n- 16 M ar- 16 What actions are we taking? The Rapid Access Improvement Scheme was introduced in January 2016 and there has been a demonstrable improvement in the two main reported access standards for Primary Care. An Access Task and Finish Group has been established to further improve access to GMS which remains a key priority for the population. Population Accessing NHS Primary Dental Care This indictor looks at the % health board population accessing NHS primary dental care. This information is not available on a cluster level. Hywel Dda has the lowest percentage of patients treated, with only 42% of adults receiving NHS dental treatment against an All Wales mean of 52.3%. Performance is better for children with 60.7% of children receiving treatment against an All Wales mean of 65.1%. What are the main areas of risk? If patients do not have access to routine dental care, their oral health can deteriorate. This will result in increased usage of specialist services (Minor Oral Surgery and Community Dental Services) and urgent dental services. What actions are we taking? 16

The Health Board has developed Routine Access Services, which allows patients (without a regular dentist) to access routine dental care. The Health Board has a Performance Management Framework for General Dental Services contracts, to ensure activity is maximised. We are investing into services. (more detail from exec paper) 6.1 Individual Care Medication review This indicator looks at whether a medication review is recorded in the notes in the preceding months for all patients being prescribed 4 or more repeat medicines. The standard/target for this indictor is 80%. The information in the Primary Care Portal is significantly out of date, 20/. Utilising CM Web as an alternative provides more timely information however this is not comparable across Wales. When broken down to a cluster level there has been an overall decrease in achievement of this indicator with performance ranging from 83% of practices achieving the target in South Pembrokeshire to 100% in North Ceredigion. 2010-11 2011-12 2012-13 2013-20- 20-16 2T 100% 100% 100% 100% 100% 100% AG 100% 88% 88% 88% 88% 88% LL 100% 100% 100% 100% 100% 89% NC 100% 100% 100% 100% 100% 100% SC&T 100% 100% 100% 100% 100% 86% NP 100% 100% 100% 100% 100% 89% SP 100% 100% 100% 100% 100% 83% HDUHB 100% 98% 98% 98% 98% 91% 6.2 Individual Care Health inequalities (Blood Pressure) This indicator looks at the % of patients aged 50 or over who have a record of blood pressure in the preceding 5 years. The information in the Primary Care Portal is incorrect and therefore CM Web data is shown which does not allow comparison at an All Wales level. 17

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HDUHB Blood Pressure (BP001W) Achievement 20-16 9 0.8 % 9 1.6 % Amman Gwendraeth 9 0.0 % 8 9.5% 8 9.0 % 8 9.8 % 9 0.5% 9 0.2 % Llanelli Taf Tywi North Ceredigion South North South Hywel Dda LHB CeredigionPembrokeshire Pembrokeshire When broken down to a cluster level, performance ranges from 89% in South Ceredigion to 91.6% in Llanelli. 6.3 Individual Care Dementia Care This indictor looks at Dementia prevalence, practices establishes and maintains a register of patients diagnosed with dementia. Prevalence has been calculated as the number of patients contained on each register, divided by the number of patients registered with the practice in question, taken from 20/ QOF data. Hywel Dda had a prevalence of 0.6% in 20/ which is the latest information in the Primary Care Portal. This is the same as the All Wales mean at the time with only two Health Boards exceeding this. Since that time the prevalence has increased to 0.64% at the end of 20/16 according to CM Web data. 18

0.64% HD Dementia Prevalence across years 0.62% 0.60% 0.58% 0.56% 0.54% 0.52% 0.50% 2010-11 2011-12 2012-13 2013-20- 20-16 At a cluster level prevalence varies between 0.51% in both Ceredigion Localities and over 0.8% in South Pembrokeshire. Dementia Prevalence 20-16 0.9% 0.8% 0.7% 0.6% 0.5% 0.4% 0.3% 0.2% 0.1% 0.0% 2T AG LL NC SC&T NP SP CA CE PE HDUHB 19

Appendix 1 Data may be subject to change as further submissions may be received. Assessment Unit activity is included within this data. Numbers are shown by Financial Month i.e. 200801 = April 2008. The 'LHB Provider Spell' methodology is used in the calculation of the number of emergency admissions for patients with one of the conditions specified in the basket of 8 chronic conditions. Use of the 'LHB Provider Spell' (often informally referred to as 'super spells') methodology for this measure has the additional benefit in that it avoids any confusion arising from concurrent Finished Consultant Episode (FCEs). Emergency hospital readmissions are defined as the same patient being admitted to the same LHB for the same chronic condition 'category' within a 12 month period (i.e. 365 days or less between the discharge date (from the original admission) and the admission date (of the subsequent admission)). Readmissions include all subsequent emergency admissions with an ICD-10 code for the same chronic condition 'category' rather than just those admissions where the individual ICD-10 4th Edition code is the same as the original admission. The initial (first) emergency admission is not counted as part of the indicator, only subsequent emergency admission. The analysis of emergency admissions includes: Inpatient admissions only (patient class = '1') All emergency admission methods, excluding emergency transfers (i.e. Admission Method '81' and Patient Classification '8'). Admissions where the admitting 'Hospital Classification Category' for the Site Code of Treatment (Hospital) is acute ('A'), major acute ('B') & specialist acute sites ('D') only. Admissions to community hospitals are excluded to avoid any possibility of double counting in the event of patients being admitted into an acute site and subsequently transferred to a community hospital. Completed provider spells only. An applicable ICD-10 4th Edition primary diagnosis code associated with the minimum (admitting) episode of the LHB Provider Spell. Velindre NHS Trust is excluded. 20