THE HEART DISEASE DELIVERY PLAN OF POWYS TEACHING HEALTH BOARD

THE HEART DISEASE DELIVERY PLAN OF POWYS TEACHING HEALTH BOARD 2013 2016

CONTENTS PAGE List of abbreviations 2 1. Background and Context 3 National Context 3 The Vision 3 The Drivers 4 Local Context 5 2. Organisational Profile; Summary of Service Provision 6 Introduction 6 Improving Health and Wellbeing 7 Overview: The Delivery of Services for Heart Disease 8 Primary and Secondary Care 8 Specialist Services 9 Patient Support Groups 9 3. Development of the Powys Teaching Health Board 10 Local Delivery Plan for Heart Disease Background 10 Development of the Powys Heart Disease Delivery Plan 10 4. Summary: The Powys Heart Disease Needs Assessment 12 Background 12 Key Messages 12 Population Health Profile 13 The Promotion of Healthy Hearts 14 The Role of Primary Care in the Management of Coronary 14 Heart Disease Fast and Effective Care 15 Improving Information and Targeting Research 15 Local Prevention Priorities 15 Local Delivery Priorities 16 5. Summary of the Plan: The Priorities for 2013 2016 17 Background: Powys teaching Health Board Integrated Medium 17 Term Plan 2014/17 Theme 1: The Promotion of Healthy Hearts 18 Theme 2: The Timely Detection of Heart Disease 19 Theme 3: Fast and Effective Care 19 Theme 4: Living with Heart Disease 20 Theme 5: Improving Information 21 Theme 6: Targeting Research 22 6. Performance Measures and Management 23 Powys Heart Disease Delivery Plan: Action Plan 2013-2016 24 1

LIST OF ABBREVIATIONS FH HB HDDP IP MI NHS OP PtHB PHW SWCN TBD WAST WHSSC Familial hypercholesterolaemia Health Board Heart Disease Delivery Plan In-patient Myocardial infarction National Health Service Out-patient Powys teaching Health Board Public Health Wales South Wales Cardiac Network To be determined Welsh Ambulance Services Trust Welsh Health Specialised Services Committee 2

1. BACKGROUND AND CONTEXT The Heart Disease Delivery Plan for Powys has been developed in response to the requirement from Welsh Government and is based on accompanying guidance and plan templates. National Context 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. The plan sets out the Welsh Government s expectations of the NHS in Wales to prevent avoidable heart disease and to plan, secure and deliver high quality personcentred care for anyone affected by heart disease. The plan focuses on meeting population need, tackling variation in access to services and reducing inequalities in health outcomes across six themes. For each theme the plan sets out: Delivery aspirations for the prevention and treatment of heart disease Specific priorities for 2013 to 2016 Responsibility for the development and delivery of actions to achieve the specific priorities Population outcome indicators and NHS assurance measures The Vision The vision for heart care in Wales 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 A range of indicators will be used to measure success. Under development, these will be refined over time and will include, for example: Coronary heart disease prevalence: % patients under 75 living with coronary heart disease Premature mortality from circulatory disease (deaths in the under 75 year old age group) Survival rates following cardiac arrest out of hospital Cardiovascular mortality in relation to average life expectancy - potential years of life lost 3

The Drivers There are good reasons for heart disease to be a key priority for NHS Wales. According to the latest information available from the Welsh Health Survey, 20% of Welsh adults are being treated for high blood pressure and 9% for any heart condition (not including high blood pressure). The most significant 1 cause of heart-related ill health and mortality is coronary heart disease (particularly angina and heart attack). Although mortality rates in Wales have been falling over the last three decades, rates remain around 15% higher than in England. In addition, mortality rates vary significantly across Wales; the rate in the most deprived fifth of wards is almost a third higher than in the least deprived fifth 2 - 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 show that major risk factors remain prevalent 3 : 23% of adults report smoking, with 20% of adult non-smokers reporting regular exposure to other people s tobacco smoke indoors 57% of adults and 35% of children are classed as overweight or obese (19% of children are obese) 43% of adults report drinking above recommended guidelines on at least one day in the previous week Only 29% of adults report being physically active on five or more days in the past week These risk factors underpin the focus on coronary heart disease and the promotion of healthy hearts as a theme. Coronary heart disease is, however, just one part of the picture; the delivery plan covers heart conditions more broadly, highlighting the importance of providing high quality detection and treatment of all major heart diseases, including: Heart failure (predominantly caused by coronary heart disease) Arrhythmia management, including the management of atrial fibrillation (frequently a consequence of coronary disease) Congenital heart disease (in children and adults) Inherited or idiopathic cardiac conditions, including the cardiomyopathies 1 Welsh Health Survey 2011, Welsh Government statistics, September 2012 2 The Cardiac Disease National Service Framework for Wales, Welsh Government, 2009 3 Welsh Health Survey 2011, Welsh Government statistics, September 2012 4

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: The promotion of healthy hearts The timely detection of heart disease Fast and effective care Living with heart disease Improving information Targeting research Local Context Cardiovascular disease (and within this, heart disease) is one of the most significant population health issues in Powys. While Powys may be perceived in an overall sense as relatively healthy within Wales, there are uncertainties and risks in adopting this position. Some of these relate specifically to heart health and are examined in more detail in the accompanying Needs Assessment. For example, does a Powys resident have the equivalent opportunity to benefit from life-savings interventions following an MI as someone living in Swansea or Cardiff? In terms of secondary and tertiary care for patients with heart disease, one of the main challenges for Powys teaching Health Board (apart from its financial position) is the complexity of acute hospital provision and patient flows to a range of Welsh and English provider organisations outside the County. In its commissioning role and through its locality model, Powys teaching Health Board has a responsibility to support and ensure that the vision and quality requirements of the national approach to heart health are being realised in all its provider organisations. Opportunities for this include close working with and through the South Wales Cardiac Network and WHSSC in their commissioning and assurance roles. In addition, this Heart Disease Delivery Plan for Powys should be seen through the prism of the Health Board s Integrated Medium Term Plan for 2014/17, which is currently under development. Most particularly, the Powys Integrated Plan encompasses and details seven transformation programmes, many of which are directly relevant to heart health - including primary prevention, primary care, unscheduled care and long-term conditions. As it stands, there are many commonalities of vision, purpose and action between these transformation programmes and the Powys Heart Disease Delivery Plan. Future delivery and governance arrangements for the Powys Heart Disease Delivery Plan will be determined in light of the Powys Integrated Plan and final decisions in relation to Plan assurance. 5

2. ORGANISATIONAL PROFILE AND SUMMARY OF CURRENT SERVICE PROVISION Introduction 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 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 6

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) Health service use Powys Wales GP in the past 2 weeks 14% 17% Attended casualty in the past twelve months 13% 17% In hospital as an inpatient in the past twelve months 8% 9% Attended outpatients in the past twelve months 31% 32% Saw a pharmacist in the past twelve months 63% 69% Attended a dentist in the past twelve months 74% 70% Attended an optician in the past twelve months 45% 49% Source: Welsh Health Survey, 2011 and 2012 (Welsh Government) Table 1: Health Service Use in Powys and Wales Improving Health and Wellbeing Health improvement priorities are articulated in the Powys Public Health Strategic Framework 2011-14, 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 7

context, it should be noted that a range of actions are in hand to improve local performance of the Stop Smoking Wales service, which is currently failing to deliver the Welsh Tier 1 smoking cessation target in Powys. Levels of investment in this service are extremely low (currently ~ 0.6WTE smoking cessation support). 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 (the latter is currently under review). 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 2014, provided from the 8

Shrewsbury and Telford Hospitals NHS Trust. echocardiography are available. 24 hour tape ECG and Specialist Services 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. 9

3. DEVELOPMENT OF THE POWYS TEACHING HEALTH BOARD LOCAL DELIVERY PLAN FOR HEART DISEASE Background In response to Together for Health A Heart Disease Delivery Plan (2013), Health Boards in Wales were required (by December 2012), together with their partners, to produce and publish a detailed local service delivery plan to demonstrate a systematic approach to progressive implementation of the Cardiac National Service Framework, the Welsh Health Specialised Service Committee Review of Cardiac Services and the national Heart Disease Delivery Plan. Following this, Heath Board Executive leads for heart disease are required to report progress formally to their Boards against local delivery plan milestones and to publish these reports on their Health Board website on at least an annual basis. Powys teaching Health Board s Executive Lead for heart disease is Dr Catherine Woodward, Director of Public Health. There is currently no dedicated officer lead. Development of the Powys Heart Disease Delivery Plan In 2010, in accordance with national requirements at that time, Powys teaching Health Board developed its Cardiac Local Delivery Plan (LDP) 2011-2015, to support local delivery across the seven standards of the Cardiac Disease National Service Framework. The multidisciplinary process to deliver this plan was supported by the Mid and SW Wales Cardiac Network and encompassed detailed baseline self assessments and service mapping. The final plan incorporated feedback received from Welsh Government. The new requirement to produce a local Heart Disease Delivery Plan will provide a useful opportunity to review progress with the Cardiac LDP in Powys, to ensure this informs the scope and content of the Powys Heart Disease Delivery Plan going forward and to develop an integrated approach. In addition, as determined by Welsh Government, the prevention and management of cardiovascular disease spans other Together for Health local plans, including diabetes, stroke and end of life care. Going beyond this, the Powys Heart Disease Delivery Plan has been developed with reference to: The Powys teaching Health Board Three Year Plan 2013/14 to 2015/16 (September 2013), now under review and development (in line with national guidance) to cover the period 2014/15 to 2016/17 (final version to be signed off by Board in March 2014) The Joint Strategic Needs Assessment for Powys The heart disease needs assessment for Powys, which was led by Public Health Wales 10

Contributions from a range of senior managers and clinicians in Powys, including the Medical Director and Powys locality general managers. There is currently no clinical lead for heart disease in Powys In terms of the WHSSC cardiac services review, WHSSC has developed a delivery plan on behalf of all Welsh Health Boards. Actions within the plan address themes 2, 3, 4 and 5 of the HDDP. The plan sets out the further work required to take forward the recommendations of the review and is common to all Welsh Health Boards. A local Steering Group will be established to implement the Powys Heart Disease Delivery Plan, although it should be noted that this may be in the wider context of work currently in hand in the Health Board in relation to long term conditions. Oversight and Board assurance of the Powys Heart Disease Delivery Plan will be through the Director of Public Health, who also represents Powys teaching Health Board on the All Wales Heart Disease Implementation Group. 11

4. SUMMARY: THE POWYS HEART DISEASE NEEDS ASSESSMENT Background The Powys heart disease epidemiological needs assessment was completed to support development and delivery of the Powys Heart Disease Delivery Plan. 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. 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. The Stop Smoking Wales service is currently failing to achieve its 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 12

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 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 13

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 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 14

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 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 15

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 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 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 16

5. SUMMARY OF THE PLAN: THE PRIORITIES FOR 2013-2016 Background: Powys teaching Health Board Integrated Medium Term Plan 2014/17 As articulated in its Three Year Plan, the overarching vision of Powys teaching Health Board is to deliver... truly integrated care centred on the individual....through five interrelated values: Improving health and well-being Ensuring the right access Striving for excellence Involving the people of Powys Making every pound count The refreshed Three Year Plan (September 2013) also encompassed the development of seven transformational programmes for Powys, which will underpin the business of the Health Board and improvements in both service quality and financial efficiencies going forward (2014/17). Detailed plans are available on request. Enablers include a programme management approach through the Health Board s new Programme Office, the development of the locality model and transformation of the Health Board s information function. Local delivery of the Heart Disease Plan should be seen in the light of the seven transformational programmes, which are: Primary prevention Primary care and community services Unscheduled care Planned care Mental health Long term conditions Integrated services for older people (encompassing dementia) The Powys teaching Health Board Heart Disease Delivery Plan is not a costed plan. It does not form a discrete part of the Health Board s current financial plan; the national expectation is that the heart plan will be delivered within current resources. However, with reference to WHSSC, Powys teaching Health Board has made considerable investment in specialised services during the last two years, despite the overall trend of cost reduction and service efficiency. This approach is not sustainable during 2014-17 (the period of the next Three Year Plan); the Health Board has already formally indicated to WHSSC an indicative expenditure level in line with 2011/12 investment. With specific reference to cardiac services for Powys, the 2011/12 WHSSC budget was 100.3 million, itself an increase of 4.7% since 2006/7, when the budget was 95.6 million. Powys is atypical within the WHSSC arrangements, in that a significant proportion of the specialised 17

services commissioned on behalf of the Powys population involve clinical pathways into English NHS services. However, the relatively low volumes of activity and high costs for some services risk an unstable financial position; the following programme of work will assist in addressing this (not all specific to cardiac services): The development of strategic relationships with WHSSC through a business partner approach, with a particular emphasis on jointly managing English contract activity To review current risk share arrangements and contribute to overall WHSSC business processes, including referral and demand management and pan-wales savings schemes To review WHSSC investments to ensure that Powys patients have received the anticipated benefits To support WHSSC prioritisation and associated de-commissioning processes Managing English WHSSC contracts to the same RTT as Wales Theme 1: The Promotion of Healthy Hearts The nationally specified priorities for 2013 16 are to: 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 change 4 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 4 Including, for example, Stop Smoking Wales, Fresh Start Wales, Change 4 Wales 18

Work is already in progress in Powys on many of these measures. Locally determined priorities are detailed in the Plan. Theme 2: The Timely Detection of Heart Disease The nationally specified priorities for 2013 16 are to: 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 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. Theme 3: Fast and Effective Care The nationally specified priorities for 2013 16 are to: 1. Organise services to ensure people admitted because of diagnosis with a heart disease are assessed by a consultant cardiologist 5, within 24 hours of admission to hospital 5 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 19

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 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. Theme 4: Living with Heart Disease The nationally specified priorities for 2013 16 are to: 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 heart disease and who undertakes regular continuing professional development of relevance to the care of patients with heart disease. 20

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 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. Theme 5: Improving Information The nationally specified priorities for 2013 16 are to: 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 In Powys, the Health Board s overall IT Strategy is aligned to the national ICT strategy, the NWIS Plan and the shared ICT platform being developed jointly with Powys County Council (through a Section 33 Agreement). The new three year strategy for ICT will include: Digital Powys a cross-public sector project jointly led by Powys teaching Health Board and Powys County Council to develop the wider ICT infrastructure in Powys as a driver for economic regeneration and sustainable communities, in addition to supporting innovative service delivery An integrated health and social care information system Continued delivery of key NWIS programmes in Powys 21

Development of a shared business case for implementation and roll-out of telehealth and telecare with Powys County Council Continued roll-out of tele-presence to support rural health care delivery and reduce transport costs for staff and patients This approach and its underpinning developments can offer important opportunities for the prevention and management of heart disease in Powys. Locally determined priorities are detailed in the Plan. Theme 6: Targeting Research The nationally specified priorities for 2013 16 are to: 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 trail scoping and service delivery modelling and assessment 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 However, some of these priorities do not reflect the current position in Powys. The only protected learning time currently available is resourced through arrangements with IRH. No specific funds are available for cardiac research. No clinical fellows or academics currently work in Powys. SAIL can extract information from primary care systems; locally, educational sessions have been provided to improve clinical recording. In light of this, the plan details local research priorities. 22

6. PERFORMANCE MEASURES AND MANAGEMENT The Welsh Government s Heart Disease Delivery Plan (2013) contained an outline description of the national metrics that Health Boards and other organisations will publish, including: 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 Indicators and assurance measures will be further developed by the All Wales Heart Disease Implementation Group. The indicators will be calculated on behalf of the NHS annually at both national and Health Board population level. Progress with these outcome indicators will form the basis of Powys teaching Health Board s heart disease annual report, which will also encompass a progress report against the milestones of the Powys Heart Disease Delivery Plan. It is anticipated that this report will also encompass assurance from WHSSC on the specific measures and actions for which it is accountable to Powys teaching Health Board. Reports will be placed on the Health Board s website. 23

Powys Heart Disease Delivery Plan Action Plan: 2013-2016 Theme 1: The Promotion of Healthy Hearts Priority Actions Expected outcome Risks to Delivery Timescales / Milestones 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 Develop local action plans for health inequalities and risk factors for coronary heart disease Increase in referrals to lifestyle support services and Stop Smoking Wales Development of a health inequalities action plan for Powys More effective targeting of resources according to need Lack of public health specialist capacity in the Powys PH team Levels of unmet need, coupled with financial position of the Health Board By April 2015 DPH Lead 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 As above plus Improved rates of smoking cessation Powys THB staff trained in and delivering brief intervention As above As above DPH 24

Every Contact Count in Powys, in line with the PtHB 3 Year Plan transformation programme 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 Improve the delivery of Stop Smoking Wales in Powys 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 Roll out of Add to Your Life in Powys Improved position and trend across a range of population health outcome measures (through Three Year Plan process) Lack of senior specialist public health capacity in Powys Implications of a rural IT infrastructure and rural population for an on-line programme Local performance of Stop Smoking Wales Lack of senior specialist public health capacity in Powys Competing priorities faced by frontline staff By April 2015 (subject to national timetable) By April 2015 then ongoing DPH DPH 25