RESPIRATORY HEALTH DELIVERY PLAN 1. BACKGROUND AND CONTEXT Together for Health a Respiratory Health Delivery Plan was published in April 2014 and provides a framework for action by Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government s expectations for the planning and delivery of high-quality person-centred care for anyone affected by a respiratory condition. For each theme it sets out: Delivery expectations for the management of respiratory conditions Specific priorities for 2013-17 Responsibility to develop and deliver actions to achieve the specific priorities Potential assurance measures The vision Our vision is for people of all ages to be encouraged to value good lung health, to be aware of the dangers of smoking and take personal responsibility for their lifestyle choices to reduce the risk of acquiring a respiratory condition and maximise the benefit of any treatment. Where problems with lung health occur, individuals can expect early and accurate diagnosis and effective treatment so the quality of their life can be optimised. Our aim is for Wales to have low incidence for lung disease and improved health care outcomes. We will use the following indicators to measure success: A reduction in prevalence of smoking as per the Tobacco Control Action Plan for Wales Incidence of Chronic Obstructive Pulmonary Disease (COPD) per 100,000 population Unscheduled hospital admissions for both asthma and COPD per 100,000 population Disease and age group specific mortality rates under age 75 per 100,000 population The Drivers: Health Statistics Wales 2013 makes clear the magnitude of respiratory conditions nationally. One in seven adults (14%) in Wales reports being treated for a respiratory condition and respiratory diseases cause one in seven (15%) of all deaths in Wales. Moreover, the Welsh Health Survey 2012, which includes lifestyle information, 12 September 2014 Version v1.0 Page 1 of 10
reveals a smoking prevalence in Wales of 23% and a prevalence of overweight and obese adults of 59%. Both smoking and obesity are major contributory factors to the levels of respiratory disease. Improving the respiratory health of the population in Wales is a major challenge for health care providers and a key opportunity to improve the lives of patients and their families. Improvements in respiratory heath care have not been achieved equally for all people and substantial differences in service provision can be found between communities. Levels of respiratory disease in areas of social deprivation are of particular concern and improved outcomes in respiratory health also need to be delivered equitably. Focus now needs to be on providing services which make the most effective use of resources, whilst measurably impacting upon the quality of life for areas of population with particularly poor lung health. What do we want to achieve? The all-wales Delivery Plan sets out action to improve outcomes between now and 2017. It focuses on meeting population need, tackling variation in access to services and reducing inequalities across six themes: Preventing poor respiratory health Detecting respiratory disease quickly Delivering fast, effective treatment and care Supporting people living with lung disease Improving information Targeting research 2. DEVELOPMENT OF BETSI CADWALADR UNIVERSITY HEALTH BOARD DELIVERY PLANFOR RESPIRATORY HEALTH In response to the Together for Health A Respiratory Health Delivery Plan (2014), Health Boards are required, together with their partners, to produce and publish a detailed Local Service Delivery Plan to identify, monitor and evaluate action needed within timescales. Heath Boards are required to report progress formally and publish the annual reports on their websites annually. 3. ORGANISATIONAL PROFILE Organisational Overview Betsi Cadwaladr University Health Board is the largest health organisation in Wales, providing a full range of primary, community, mental health and acute hospital services for a population of around 676,000 people across the six counties of North Wales (Anglesey, Gwynedd, Conwy, Denbighshire, Flintshire and Wrexham) as well as some parts of mid Wales, Cheshire and Shropshire. We employ around 16,100 staff and have a budget of around 1.2 billion. We are responsible for the operation of three district general hospitals (Ysbyty Gwynedd in 12 September 2014 Version v1.0 Page 2 of 10
Bangor, Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital) as well as 18 other acute and community hospitals and a network of over 90 health centres, clinics, community health team bases and mental health units. The Health Board also coordinates the work of 114 GP practices and NHS services provided by North Wales dentists, opticians and pharmacies. The program budget for respiratory care in 2012-13 was almost 87 million, of which 34.8% was spent on emergency care (above the Welsh average) and 29.6% on primary care (below the Welsh average) The Health Board s clinical services are divided into 11 Clinical Programme Groups (CPGs) and respiratory health falls into the remit of the Primary, Community and Specialist Medicine CPG. However, the Pharmacy and Medicines Management CPG and the Therapies and Clinical Support Services CPGs also play a significant role, as does Public Health Wales support for prevention and well being. For this reason, a Respiratory Steering Group was set up in late 2012 with membership from all relevant CPGs, patient representatives, finance, secondary and primary care and public health. Members are multi disciplinary from clinical and non clinical backgrounds and from all areas of North Wales. The Group chose to focus on three conditions: COPD, asthma in adults and Community Acquired Pneumonia (CAP). An Action Plan was developed following a well attended workshop in January 2013 and clear priorities were established for all three conditions. The Group has continued to meet and to work on these priorities since then, with continued clinical engagement and some successes in implementing priority actions. The Health Board is reviewing its structures currently so operational arrangements will change. However, it has been agreed that the existing Respiratory Steering Group will become the BCUHB Respiratory Health Planning and Delivery Group with a formal Programme supported by a Project Manager from Autumn 2014. The Group is currently reviewing its Terms of Reference and the majority of members are keen to continue their commitment. Overview of local health need and challenges to respiratory services The population is diverse, with urban and rural areas and seaside towns. The incidence and prevalence of respiratory disease is linked to smoking and obesity, which are linked to deprivation. We have people living in deprived areas, which tend to be dispersed with some urban industrial areas (Deeside) and pockets of rural poverty. An initial assessment of need and challenges was made in early 2013: the key messages were as follows: Public health BCUHB has the largest number of people aged 65 years and over in the population. The proportion of the population aged 65 years and over is above the average for Wales. 12 September 2014 Version v1.0 Page 3 of 10
BCUHB has a similar lifestyle to Wales in terms of health related behaviours: Smoking prevalence in BCUHB is the same as the average for Wales, and varies from 18% to 32%; The age standardised mortality rates for bronchitis and emphysema in persons aged 75 years and under is lower than the average for Wales. The age standardised mortality rate for asthma in BCUHB is just below the average for Wales Health care About 80% of people diagnosed with COPD and over 70% of people diagnosed with asthma had an annual review within the previous 15 months, with variation between practices and age groups. There were over 5,400 emergency admissions for COPD, asthma and pneumonia in 2011-12, and over 23,000 where one of these conditions was recorded as a co-morbidity. There is significant variation in length of stay, activity, admission rates and cost between the three hospitals, the reasons for which are not fully understood Quality and safety Measures such as hospital readmission rates and risk adjusted mortality rates (RAMI scores) in BCUHB as a whole are similar to, or lower than, peer organisations. Medicines The annual cost of respiratory medication prescribed by General Practice for 2011-12 was: 18,121,000 and increased by 3.1% over the previous year. The respiratory programme budget is potentially a higher spend than expected, as the population has a generally lower rate of respiratory conditions than comparator HBs. The cost of respiratory care in BCUHB is 10% higher than the rest of Wales The respiratory program budget for 2010-11 was 86.8 million. 23.8 million (27.3%) of this was within Primary Care, 55.1 million (63.5%) in Secondary Care and a further 7.9 million (9%) with other providers, This is over 7% of the overall spend for BCUHB and nearly 10% of the admitted care spend. The average cost per admission per day for these three conditions is 370, with significant variations between sites for the proportion admitted from Emergency Departments (ED), number of admissions, length of stay, cost per admission and cost per day. 12 September 2014 Version v1.0 Page 4 of 10
54% of costs related to direct treatment such as ward, medical pay and drugs, with a further 13% in clinical support costs and 33% in non clinical and overheads. The Group chose three priority conditions to focus on, for reasons of burden of disease, room for improvement in patient experience and outcomes and potential for cost efficiencies. Our Action Plan from January 2013 was: COPD 1. Develop COPD Local Enhanced Service (LES) 2. Pulmonary Rehabilitation 3. Develop linkage with Palliative care 4. Locality based multi-disciplinary working 5. Improved training on inhaler technique to Patients and health professionals Asthma 6. Develop asthma step up/step down toolkit in conjunction with above, e.g. Asthma UK or British Lung Foundation (BLF) step down toolkit 7. Locality based asthma review clinics 8. Identify patients who rely on unscheduled care for support and actively manage within primary care Community Acquired Pneumonia 9. Clarify and implement formulary for pneumonia, reduce unnecessary use of intravenous antibiotics, in particular Tazocin 10. Eliminate use of 250mg Amoxicillin as primary treatment, Community pharmacists to work with GP Practices. 11. Standardised use of CURB/CRB scoring Generic 12. Develop robust communication mechanism for updates to guidelines and pathways 13. Improved communication between primary and secondary care at both referral and discharge 14. Smoking Cessation 15. Variations in spend across North Wales between similar services. 16. Medicines Management Identify further areas for improvement in quality, outcomes or value for money and mechanisms to deliver change 17. L.U.N.G. (Lining Up with Necessary Guidance) Prudent Health care approach In early 2014, a Project led by Bangor University took a Programme Budgeting and Marginal Analysis approach to how the current respiratory spend could be best invested for the best outcomes, patient experience and greatest efficiency. This used a well established and transparent, method that can take account of evidence and stakeholders preferences and judgements on feasibility. A number of ideas for investment and disinvestment were investigated and presented, bearing in mind that proposal intended a partial and possibly quite small shift away from one area and not 12 September 2014 Version v1.0 Page 5 of 10
a total stop to any programme. The recommendations for priorities for shifting investment were: Figure 1: Ranked order of candidates for investment Weighted Count of Votes Figure 2: Ranked order of candidates for disinvestment Weighted Count of Votes Note: Mis diagnosis= there is evidence of incorrect diagnosis of COPD and asthma, leading to overtreatment, inappropriate treatment, higher costs and poorer patient outcomes. The panel felt it was important to state that though misdiagnosis was ranked fourth, this was not to say this wasn t a priority. We do not wish to misdiagnose anyone; however, this will take time with training and perhaps the establishment of methods such as spirometry as part of standard diagnostic processes. Skill mix= using opportunities to explore better use of generalist rather than specialist physicians, advanced practitioners, specialist nurses etc. as an alternative to consultant level specialists. 12 September 2014 Version v1.0 Page 6 of 10
4. SUMMARY OF THE PLAN - THE PRIORITIES FOR 2014 17 Following the completion of the Action Plan, the priority setting of the Programme Budgeting and Marginal Analysis Project, and consultation with members of the Respiratory Clinical Pathways Steering Group, the key findings have been incorporated into our delivery plan for respiratory health. This delivery plan includes actions against each of the 2017 milestones within the Welsh Government Respiratory Health Delivery Plan (2014). Preventing poor respiratory health Smoking cessation: o in 2013-14, we achieved 3.8% of smokers starting treatment with specialist services against the Tier 1 target of 5%. o Identification of people that would benefit from support to quit and engaging them in the best support for them Flu vaccination rates in 2013-14 were: o Over 65s 70.7% against target of 75% o Those under 65 with chronic respiratory condition 53.2% against target of 75% o Overcoming myths and apathy among health care workers and the public Obesity o Obesity is a cause of respiratory conditions such as obstructive sleep apnoea-hypopnoea syndrome (OSAHS), and can exacerbate many others o Obesity rates among children and adults are very high and increasing Smoking cessation o Increasing demand among smokers, especially manual workers and pregnant women, for smoking cessation support o Ensuring ALL health professionals have up to date information on what services are available to them to promote to their patients o Using the opportunity of hospital OPD attendance and admission to engage smokers in a quit attempt o Increasing access through new models and wider access to Pharmacy Level 3 service Flu vaccination o Implementing the BCUHB seasonal Flu Plan Implement fully the Obesity Pathway Detecting respiratory disease quickly Early identification and correct diagnosis of those with respiratory conditions Our solutions are: Identifying target population 12 September 2014 Version v1.0 Page 7 of 10
o through GP QOF registers o community pharmacists, o public campaigns o Ensuring appropriate diagnostic tools used and staff can interpret results. Providing access to high quality diagnostic spirometry within the community The pulmonary physiology department will become an ARTP accredited training centre and offer a programme of education to primary care clinicians for the diagnosis of COPD and asthma Pilot a mobile diagnostic unit to see if we are able to undertake mannitol challenge and NIOX measurement in primary care. Delivering fast, effective treatment and care To standardise the approach to the pharmacological management of asthma and COPD and Community Acquired Pneumonia. To reduce hospital admissions and length of stay Local guidelines for the management of asthma and COPD will be written and disseminated Implement standardised use of CURB/CRB scoring for Community Acquired Pneumonia, with adherence to antibiotic formulary Fund our business case for expansion of the pulmonary rehabilitation service Ensure that primary and secondary care clinicians work collaboratively to deliver healthcare for patients o Direct phone line and email access pilot o Locality based working: multi disciplinary clinic o Fast and full transfer of care information o Implement BCUHB Prioritisation Panel Outpatient follow up Principles o Review skills mix across primary and secondary care, with task shifting Early and supported discharge from hospital o Roll out of PORT scheme o Links with Community pharmacy (Discharge Meds review service); o All patients with an exacerbation of asthma that attend the ED or Out Of Hours (OOH) service will be seen by a primary care clinician within 2 working days, and in a secondary care respiratory clinic within 1 month Supporting people living with lung disease To support self management and empowerment and resilience in people living with respiratory conditions and their families and carers. To improve quality of life, health outcomes, and reduce inequalities in those with respiratory conditions 12 September 2014 Version v1.0 Page 8 of 10
Our solutions are: Equitable access to appropriate exercise and/or education, such as Pulmonary Rehabilitation course, National Exercise Referral Scheme, support groups Reviews from key health worker at regular intervals, with an agreed management plan Ensuring appropriate support based on the What really matters conversation Ensuring equitable access to healthy environments and the ability to make healthy choices All patients with asthma and COPD will be provided with a written management plan To ensure adequate and appropriate access to pulmonary rehabilitation for patients that would benefit from this treatment, with equitable access to those in deprived and rural areas. Increase participation in the LES for enhanced management of COPD in General Practice Inhaler technique training Reduce use of mucolytics (drugs used to treat sticky excess sputum in people with chest conditions, but poor evidence of effectiveness in COPD) Maximising the opportunities offered by hospital attendance and admission for smoking cessation Ensuring appropriate links to support agencies such as Care and Repair for adaptations in the home, social services, income and welfare advice etc. Improving information Transfer of information between all those involved with the patient pathway Disease and lifestyle appropriate information Coproduction skills among the public and among health care workers Our solutions are: Take a whole pathway approach to ensure that relevant and consistent information is given at relevant times and repeated (from diagnosis, to discharge from hospital to end of life care) o Health care workers education in shared decision making, and motivational interviewing o Medicines review service through pharmacies o Emergency medicine packs with training on how to use them Improving the reach and impact of education such as group rather than individual sessions. Patient and staff education in self management and shared decision-making Patient passports educating people as to what they should expect to receive 12 September 2014 Version v1.0 Page 9 of 10
Targeting research Little prior experience with clinical research in North Wales Our solutions are: Work with All Wales Lung research group to promote existing research projects to: patients, other healthcare professionals Engage with local Universities, such as Bangor and Glyndwr on opportunities to engage with medical, nursing, psychological and public health intervention research, in particular on improving patient outcomes and experience. Engage with and participate in at least one national clinical trial Foster culture of clinically applicable research among consultants Collaborate with ongoing clinical trials taking place in medical oncology, and primary care Explore whole system approach to exercise and education 5.0 PERFORMANCE MEASURES/MANAGEMENT The Welsh Government s Respiratory Health Delivery Plan (2014) contained an outline description of the national metrics that Health Boards will need to consider. Progress against these NHS outcomes and assurance measures will form the basis of each Health Board s annual report on respiratory services. They will be calculated on behalf of the NHS annually at both a national and local population level. Health Board s delivery plans and their milestones will be reviewed and updated annually. 12 September 2014 Version v1.0 Page 10 of 10