Hywel Dda University Health Board Draft Operational Plan 20/17 Version: 2 nd June 20 Status: Work in Progress Table of Contents Context... 2 Governance of the Plan... 4 Summary... 5 Strategic Objectives... 6 Strategic Objectives 1-8... 6 Unscheduled Care... 34 Unscheduled Care Forward Programme... 36 Planned Care... 39 Planned Care Forward Programme... 40 Follow Up Care... 41 Diagnostics... 42 Cancer... 43 Stroke... 47 Stroke Care Forward Plan... 49 Supporting and Enabling Plans... 55 Governance Plan Actions... 55 Workforce, Education and Organisational Development... 61 Commissioning, Collaborative Working, Research and Development and Innovation... 63 Infrastructure, Estates and Capital Planning... 64 Information Management and Technology... 65 Quality and Patient Experience... 66 Welsh Language... 82 Equality... 85 Carers... 85 Communications and Engagement... 86 Hywel Dda Health Charities... 91 Planning Cycle including Delivery Plans and National Implementation... 93 2017/18 2019/20 Integrated Medium Term Plan Development... 93 Service Strategy... 93 Conclusion... 94 Hywel Dda University Health Board Operational Plan 20/17 Page 1
Context Our Integrated Medium Term Plan (IMTP) 20/17 to 2018/19 signals a significant and profound change of emphasis for Hywel Dda University Health Board based on our desire to be recognised as a Population Health Organisation not simply the provider of health services. We are shifting our focus decisively towards the promotion of good health, prevention of illness, systematic disease management and holistic care coordination. We must also ensure that we are efficient in the way we use taxpayers money and as a minimum deliver on the targets set for us by Welsh Government. In light of this, we are focusing our efforts on the 10 things which will best support the health of our local population being mindful of issues of equity and equality as follows. Our 10 Strategic Objectives: 1. To encourage and support people to make healthier choices for themselves and their children and reduce the number of people who engage in risk taking behaviours. 2. To reduce overweight and obesity in our local population. 3. To improve the prevention, detection and management of cardiovascular disease in the local population. 4. To increase survival rates for cancer through prevention, screening, earlier diagnosis, faster access to treatment and improved survivorship programmes. 5. To improve the early identification and management of patients with diabetes, improve long term wellbeing and reduce complications. 6. To improve the support for people with established respiratory illness, reduce acute exacerbations and the need for hospital based care. 7. To improve the mental health and wellbeing of our local population through improved promotion, prevention and timely access to appropriate interventions. 8. To improve early detection and care of frail people accessing our services including those with dementia specifically aimed at maintaining wellbeing and independence. 9. To improve the productivity and quality of our services using the principles of prudent health care and the opportunities to innovate and work with partners. 10. To deliver, as a minimum requirement, Outcome and Delivery Framework Targets and specifically eliminate the need for unnecessary travel and waiting times, as well as return the organisation to a sound financial footing over the lifetime of this Plan. Each of the strategic objectives 1 to 8 has been expressed in terms of the ambition we have set ourselves a measurable set of targets against which we can monitor our progress. Strategic Objectives 9 and 10 focus on addressing our underlying financial position, delivering on national performance targets, whilst ensuring our services are efficient and effective and that we do not ask patients to travel unnecessarily or wait unduly. As a first step, we must ensure we are as efficient as we can be which is why we have established a Quality, Innovation, Productivity and Prudency (QIPP) work stream which aims to deliver almost 80million of improvements over the next three years, whilst holding or improving quality. We are focusing efforts on reducing our burgeoning variable pay bill which has surpassed 39million in 2015/ an unprecedented level of expenditure for us. We believe that with the work we have done already and with a clear delivery plan for next year, we can significantly reverse this trend and have targeted 11million in 20/17, as part of an overarching QIPP savings target of 29.4million in 20/17. This is ambitious but will return us to the levels of variable pay spend we experienced in 2014/15 a high water mark in itself at the time. Together with a 1% general efficiency target across our direct budgets in 20/17 we believe we can generate 29.4million in efficiency savings, forecasting that 20/17 will see our underlying deficit position stabilise and improve. Our Organisational Values are to always put people at the heart of everything we do, to work together, work as one to be the best we can be and strive to deliver and develop excellent services. These will run through our strategic objectives as common themes. In doing this, we also wanted the plan to be far more purposeful by reflecting: A sharper focus on actions we will take our plans will be framed in terms of what we intend to deliver, by when and with measurable targets to provide assurance on delivery. Hywel Dda University Health Board Operational Plan 20/17 Page 2
Evidence that we have embraced the principles of Prudent Healthcare. A strategic approach to workforce planning. Whilst our workforce represents our greatest strength, the challenges associated with recruitment and retention of staff with the right skills also represents the greatest risk to the sustainability of high quality clinical services. Addressing the challenge in these areas is central to, and underpins, our planning. In order to meet the needs of the population and be consistent with our vision and values our 10 Strategic Objectives focus the drive for improvement for our population. In arriving at each Strategic Objective, 1 to 8 relates to wellness and prevention approaches to care, whilst 9 and 10 relate primarily to efficiency and performance. This Operational Plan for 20/17 largely follows the format of the Hywel Dda Integrated Medium Term Plan 20/17 2018/19, first detailing the current priorities and plans being developed for our newly adopted 10 Strategic Objectives. This remains work in development as formal groups are being initiated with Executive Leadership and with clinical engagement to refine both in-year and longer-term delivery targets. This includes key savings and activity plans under Strategic Objectives 9 and 10. Further, just as the Integrated Medium Term Plan included a range of supporting and enabling plans, this Operational Plan includes in-year delivery for the same. Hywel Dda University Health Board Operational Plan 20/17 Page 3
Governance of the Plan Delivery against all of the 10 Strategic Objectives will be managed through the main Committees of the Board, whilst delivery of Strategic Objective 9 and the Quality, Innovation, Productivity, Prudent Sub-programmes will be managed by the Executive Programme Steering Group, chaired by the Director of Finance, Planning and Performance. The governance is illustrated as follows: University Health Board Business Planning and Performance Assurance Committee Business Intelligence Unit identifies through benchmarking our future business opportunities Executive Team Sub Committee QIPP Executive Programme Steering Group Internal Performance Group Integrated Performance Management Team tracks in-year performance in its widest sense Strategic objectives 1 8 1. Risk Taking Behaviours 2. Overweight & Obesity 3. Cardiovascular Disease 4. Cancer 5. Diabetes 6. Respiratory Illness 7. Mental Health & Wellbeing 8. Frailty and/or Dementia Strategic objective 9 - Productivity & Quality 1. Referral Management 2. Acute care productivity and efficiency 3. Medicines optimisation 4. Learning disability shifts to community settings 5. Unscheduled care improved flow 6. Patient care focus for clinicians 7. Improved workforce planning to match forecasted demand 8. Continuing healthcare 9. Improved procurement 10. Variable pay Strategic objective 10 Outcome and Delivery Framework Targets Programme Management Office Plan Reporting Committee Workforce, Education and Organisational Development Quality, Safety and Patient Experience Collaboratives Business Planning and Performance Assurance Research and Development University Partnership Board Capital Planning and Estates Business Planning and Performance Assurance Information Management and Technology Business Planning and Performance Assurance Governance of the Board Audit Supporting and Enabling Plans Across All Strategic Objectives Quality and Safety Quality, Safety and Patient Experience Patient Experience Quality, Safety and Patient Experience Equality Quality, Safety and Patient Experience Welsh Language Quality, Safety and Patient Experience Carers Quality, Safety and Patient Experience Communications and Engagement Quality, Safety and Patient Experience Hywel Dda Health Charities Charitable Funds Finance Business Planning and Performance Assurance Hywel Dda University Health Board Operational Plan 20/17 Page 4
Summary The following chart is designed to provide a summary overview of our key deliverables contained in our Operational Plan for 20/17. Strategic Objective Strategic Objectives 1-8 Strategic Objective 9 Strategic Objective 10 Supporting and Enabling Plans Key Deliverable Quarter 1 Quarter 2 Quarter 3 Quarter 4 Broadly, each objective will undertake the following quarterly deliverables Establishment of SO Groups Development of PID Development of metrics Validation of PID and metrics Implementation of work programme Implementation of work programme Review Savings Target m (cumulative) 5,598 12,659 21,094 29,400 Financial Position m (cumulative) 10,407 19,751 28,962 38,300 RTT 26 weeks (%) 82% 83% 84% 84% RTT 36 week waits (numbers) 4125 3750 3375 3000 Diagnostics (maintain zero waits over 8 0 0 0 0 weeks) Stroke (new in 20/17) % Direct admission to stroke unit 55% 59% 66% 74% within 4 hours CT scan within 12 hours 95% 95% 95% 95% Assessed by a Stroke nurse within 53% 59% 65% 71% 24 hours Formal swallow assessment in 72 91% 92% 94% 95% hours Cancer (urgent / non urgent suspected 90.2% / 98% 91.4% / 98% 93.6% / 98% 93.6% / 98% cases) (%) A&E 4 hour waits (%) Original/Revised 87% / 86% 90% / 87% 92% / 87% 91% / 88% 1 hour handover Original/Revised 83 / 85 27 / 27 14 / 17 5 / 5 Clinical Response Model - 8 minutes 65% 65% 65% 65% (%) C Difficile (n) 28 28 28 28 Reduction in DToC rate per 10,000 58.5 58.0 57.5 57.0 UHB population non mental health Reduction in DToC rate per 10,000 UHB population mental health 3.6 3.3 3.2 3.2 Governance Plan Workforce, Education and Organisational Development Commissioning, Collaboratives, Research and Development and Innovation Infrastructure, Estates and Capital Planning Summary cannot be provided as plans are all very different so please Information Management and refer to sections Technology Quality and Patient Experience Welsh Language Equality Carers Communications and Engagement Hywel Dda Health Charities Hywel Dda University Health Board Operational Plan 20/17 Page 5
Strategic Objectives Strategic Objectives 1-8 Whilst the Strategic Objectives are based on the health needs of our population, the development of each must be underpinned and strategically linked with the aims of our QIPP programme. By the end of May 20 it is expected that Executive Leads with their Clinical Leads will have held a meeting to check and challenge with a view to confirming the in-year delivery aims for each Strategic Objective. This will then be the subject of regular Committee and Board monitoring reporting. The Integrated Medium Term Plan and the annexes contain a wide-range of action and work plans which will continue to be progressed in parallel with the milestones outlined above to ensure that the momentum for delivery of schemes and initiatives which impact on the achievement of our Strategic Objectives is maintained. The table below sets out the scale of our ambition for Strategic Objectives 1-8 which are draft at this stage pending the completion of the check and challenge process described above. Final Board approval will be sought once this process is complete Strategic Objective and Executive Lead Strategic Objective 1: To encourage and support people to make healthier choices for themselves and their children and reduce the number of people who engage in risk taking behaviours Executive Lead: Director of Public Health Strategic Objective 2: To reduce overweight and obesity in our local population. Executive Lead: Director of Public Health Strategic Objective 3: To improve the prevention, detection and management of cardiovascular disease in the local population. Executive Lead: Medical Director Strategic Objective 4: To increase survival rates for cancer through prevention, screening, earlier diagnosis, faster access to treatment and improved survivorship programmes. Executive Leads: Director of Public Health and Director of Operations Strategic Objective 5: To improve the early identification and management of patients with diabetes, improve long term wellbeing and reduce complications. Executive Lead: Director of Commissioning, Therapies & Health Sciences Strategic Objective 6: To improve the support for people with established respiratory illness, reduce acute exacerbations and the need for hospital based care. Aims To reduce smoking prevalence to % by 2020 To reduce the number of individuals drinking above the daily recommended guidelines by 1% by 2020 To reduce the number of individuals reporting binge drinking on a weekly basis by 2% by 2020 Sexual health Finalising indicators but considering rates of Teenage pregnancy rates and STI data To reduce adult obesity by 0.5% by 2020 To reduce childhood obesity by 1.0% by 2020 Hypertension - Increase the number of patients aged >50 who have had their blood pressure measured. Target 92% Atrial Fibrillation - increase the number of patients diagnosed with Atrial Fibrillation who are on anticoagulation medication. Target 90% Mortality - continuous improvement of 30 day mortality rate post event for Myocardial Infarction (MI) and stroke To increase uptake of bowel screening by 5% by 2020 To meet all NHS Outcomes Framework referral and access targets Work is underway to indentify improved survival rate and experience targets; and increased rate of patients on end of life pathways including chosen place of death Increase the number of completers of the Foodwise Programme by 50% over the next 12 months Increase the number of annual reviews undertaken in the Community by Diabetic Specialist Nurses by 30% over the next 12 months Increase the number of people diagnosed with Type 2 Diabetes completing an education programme by 30% over the next 12 months Reduce the rate of amputations for patients diagnosed with Type 2 Diabetes by 0.4% over the next 12 months Increase the number of community based pharmacies providing level 3 smoking cessation services by 30% over the next 12 months Increase the number of smokers attending secondary care smoking cessation services by 15% over the next 12 months Increase the number of people attending a self management programme/pulmonary rehabilitation by 20% over the next 12 months Hywel Dda University Health Board Operational Plan 20/17 Page 6
Executive Lead: Director of Commissioning, Therapies & Health Sciences Strategic Objective 7: To improve the mental health and wellbeing of our local population through improved promotion, prevention and timely access to appropriate interventions. Executive Lead: Director of Operations Strategic Objective 8: To improve early detection and care of frail people accessing our services including those with dementia specifically aimed at maintaining wellbeing and independence. Executive Lead: Director of Commissioning, Therapies & Health Sciences Increase the number of patients attending a self management programme including pulmonary rehabilitation provided with a self management plan by 25% over the next 12 months Increase the number of healthcare professionals attending ARTP accredited spirometry training by 50% A target is being developed in relation to a reduced rate of admissions and readmissions of acute exacerbations To ensure that LPMHSS assessments are undertaken in 28 days Therapeutic interventions to start within 28 days Residents in receipt of secondary Mental Health services with a Care & treatment plan Patient receipt of outcome assessment reports Advocacy services offered 10% increase in the detection and diagnosis of maternal mental health problems Reduce the percentage of adults with a common mental disorder within the University Health Board population in line with the National levels Reduce the use of Police custody as a place of safety for Section 136 by 60% Development of SF36 reporting metrics and exploring validated tools for local use To increase the percentage of individuals with dementia accessing diagnosis in line with Ministerial Targets Increase early detection and diagnosis rates for the management of frailty Develop and implement robust frailty pathways in both community and acute hospitals in order to increase the proportion of frail people who are able and retain life skills Individual detailed action and work plans are in place some directly align to Strategic Objectives whilst others cut across objectives, examples of these are, Public Health Action Plan, Primary and Community Delivery Agreements, Together for Health Delivery Plans. This operational plan therefore references these plans and navigates to them where appropriate. We will work to distil the detail of the plans and align with Strategic Objectives in Quarter 1. Hywel Dda University Health Board Operational Plan 20/17 Page 7
Percent 1 Risk Taking Behaviours To encourage and support people to make healthier choices for themselves and their children and reduce the number of people who engage in risk taking behaviours. Background Lead Executive Teresa Owen Lead Clinician (Trends/Trajectory to follow awaiting Public Health trend analysis by 20 th May 20). Senior Responsible Officer Michael Thomas This objective relates to three main areas: smoking, sexual health and alcohol and substance misuse. Therefore each section will detail the three elements. SMOKING Smoking places a significant burden of illness on the health of individuals, communities and the Hywel Dda population and continues to be the largest single preventable cause of ill-health and premature death. The NHS Outcomes Framework (20/17) specifies the following outcome indicators and performance measures: Percentage of adults (aged +) who reported that they are a smoker (either daily or occasionally). Percentage of smokers making a quit attempt via smoking cessation services and the CO validated rate. The percentage who smoke during pregnancy. Smoking Prevalence: Smoking prevalence continues to decline with the 20 target of 20% being achieved overall across Hywel Dda UHB (HDUHB). Despite this, however, higher rates of smoking prevalence persist in the most deprived parts of the UHB and the gap between the most and least deprived fifth has widened. Smoking Prevalence in Hywel Dda University Health Board (2003/4-2013/14). Source: Welsh Health Survey 30 25 27 20 20% Target (20) % Target (2020)) 20 15 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&14 Hywel Dda Wales Smoking prevalence continues to be addressed through preventing uptake and supporting smoking cessation. If no action is taken on tobacco control the 2020 target (% smoking prevalence) and the Welsh Government Tier 1 Targets will not be achieved. In addition the gap between the most and least deprived fifth will continue to increase with this being reflected in limited or no improvement in smoking attributable hospital admissions and smoking attributable mortality. Smoking Cessation: Few interventions are associated with greater health gains than those that support smoking cessation. An evidence based smoking cessation service is defined as including behavioural support (individual or group counselling), which is offered weekly for at least 4 weeks following the set quit date with pharmacotherapy (NRT; Varenicline or Hywel Dda University Health Board Operational Plan 20/17 Page 8
Number Bupropion) (NICE, 2008). Smokers are four times more likely to succeed in achieving and sustaining a quit attempt via these services than quitting alone (NICE, 2008). There are an estimated 62,000 smokers across Hywel Dda, based on the current 20% smoking prevalence rate for Hywel Dda (Welsh Government, 2015). A 5% rate of smokers attempting cessation using specialist services would see an average of 750 quit attempts per quarter; 250 quit attempts per month. During quarter periods 1 to 3 (2015/), 898 (1.4%) smokers were treated by specialist cessation services, in comparison to the target of 3000 smokers required annually to achieve the 5% target. This represents a small improvement in performance over previous years (see Graph below). 4000 3500 Treated Smokers in Hywel Dda University Health Board, 2011-12 to 2015-3000 2500 2000 1500 1000 1020 893 1029 934 1100 500 0 1.4 1.3 1.5 1.4 1.8 2011-12 2012-13 2013-14 2014-15 2015- Treated Smokers (no.) Treated Smokers (%) Annual 5% target Linear (Treated Smokers (no.)) There has also been an improvement in Carbon Monoxide (CO) validated quit rates (see Graph below) with all cessation services in 2014/15 and 2015/ being consistently higher than the 40% tier 1 target when compared to performance in 2013/14. Hywel Dda University Health Board Operational Plan 20/17 Page 9
Percent 70.0 Percent treated smokers CO validated as quit at 4 weeks, quarters 1-4 2013-14, quarters 1-4 2014-15 and quarters 1-3 2015-. 60.0 50.0 40.0 30.0 20.0 10.0 2013-14 2014-15 2015-0.0 Q1 Q2 Q3 Q4 However, modelling work suggests that the HDUHB will continue to underperform against the smoking cessation target and the target will not be achieved unless there is a significant increase in the numbers of smokers accessing specialist cessation support, and in the amount and variety of cessation services available to serve the diverse needs of the Hywel Dda population. SEXUAL HEALTH Sexual Health is increasingly becoming a public health issue, and there have been a number of national documents produced by Welsh Government to set goals, priorities and describe what a modern sexual health service should look like. There is a lot of good work and effort being put into improving the sexual health of the population. The specialist sexual health service provides specialist care to the population, but sexual health encompasses much more than that ranging from other secondary care specialities such as gynaecology, through to C-card schemes in the community and Sex & Relationships Education (SRE) classes in schools. Despite all of this, there are still rising levels of some Sexually Transmitted Infections (STIs) and high levels of teenage conceptions for Wales as a country. In Hywel Dda University Health Board the headline figures show that the area compares well to Wales as a whole STI trends are following the same patterns and rates of teenage conceptions and terminations are generally lower. However there is still scope for improvement. Historically there has been difficulty in obtaining good data for sexual health measures in Hywel Dda due to the lack of an IT system in the service and the way that data is collected. Improving sexual health is not just about reducing the rates of STIs and teenage conceptions. As well as improving the health of the population, investment in sexual health can help to reduce inequalities, and can also deliver healthcare savings through preventing unplanned pregnancies and reducing the transmission of infections including HIV. A Needs Assessment was undertaken as the first step in a process of change and was used to inform the Hywel Dda Sexual Health Working Group, in discussions with stakeholders, to develop a Sexual Health Strategy for Hywel Dda and a subsequent Business Case to drive forward service improvement. ALCOHOL AND SUBSTANCE MISUSE Tackling drug and alcohol misuse is a complex challenge which cannot be tackled by one agency in isolation. The effects of alcohol and drug misuse are far reaching and it can and does impact on children, young people, adults, whole families and communities. Within Hywel Dda 22% of adults binge drink on at least one day per week. Alcohol related harm is increasing and more people die from alcohol related causes than breast cancer, cervical cancer and Hywel Dda University Health Board Operational Plan 20/17 Page 10
Treated Smokers (PERCENT) MRSA infection combined. Excess alcohol consumption is a major contributing factor to the risk of cancer. Recent data shows that over 5000 bed days were related to alcohol conditions costing over 5.2 million per year in inpatient treatment. Ambition SMOKING Our ambition as a University Health Board is to work with key service providers to ensure that the significant investment in services during 2015/ is reflected in an improvement in the number of smokers becoming treated and in maintaining/improving current performance relating to CO validation rates. The graph below not only provides an overview of expected projected service performance for 20/17, following the expansion of both the Pharmacy Level 3 Smoking Cessation Services and the Hospital Smoking Cessation Service, but also provides an estimation of performance if service targets are met through concerted action to address identified deficiencies in current service delivery (See next section). We want to see each service achieve the following targets in 20/17 (the Expected trajectory on the Graph below): Each Pharmacist successfully treat an average of 2 smokers per month in 20-17 with this improving in 2017-18, through ongoing investment in recruitment, training and promotion, to meet the service target of 4 smokers per provider per month. Each Hospital Smoking Cessation Advisor successfully treats an average 10 smokers per month. Stop Smoking Wales improve on current performance to move from treating 1.0% of smokers to achieve the 2.8% target agreed for this service. Improvement in referrals from primary care into the hospital cessation service; especially for those patients that are waiting for elective surgery or have a chronic condition. In addition to the above we would want to see maternity services taking a more proactive role in identifying pregnant women that smoke to ensure all children have a healthy start in life. All Midwives CO Validate 100% pregnant women at the antenatal booking appointment and all those with a CO reading of 4ppm are referred to a specialist smoking cessation service. 7.0 Combined Service Performance (SSW, PL3, Hospital) Trajectory for Treated Smokers, Percent (20-17) 6.0 5.8 5.0 4.0 3.0 3.2 2.0 2.0 1.0 0.0 Q1 Q2 Q3 Q4 Expected Achieving Service Targets No Action Tier 1 Target SEXUAL HEALTH Sexual health is an important area of public health. Access to high quality sexual health services improves the sexual health and wellbeing of both individuals and populations. An integrated sexual health service using a hub and spoke model of care, working with general practice and linking Hywel Dda University Health Board Operational Plan 20/17 Page 11
into local outreach work, will improve the sexual health of the population of Hywel Dda. This will provide easy access to services through open access one stop shops, where the majority of sexual health and contraceptive needs can be met on one site, usually by one professional, at one visit, in services with extended opening hours in accessible locations, diverting care of patients from secondary care into a community care setting. Currently specialist sexual health care within Hywel Dda University Health Board is delivered across 15 venues, many of which are not fit for purpose. The health care needs assessment identified that the services delivered in these venues are inequitable and vary from separate GUM and FP provided in a non-integrated way to open access, integrated sexual health care. The needs assessment also identified challenges faced by the service which included poor quality facilities i.e. shared spaces cluttered with other service equipment, lack of information technology infrastructure and limited data collection. There is an expectation that the population of Wales receives good quality, seamless sexual health care through an integrated sexual health service. A large evidence base supports the provision of sexual health care through an integrated sexual health service, with its provision being supported by current accredited training programmes and guidance from relevant professional bodies along with relevant national policy and guidance. An integrated sexual health service ensures the delivery of high quality seamless sexual health care by providing open access to one stop shops where the majority of sexual health and contraceptive needs can be met at one site usually by one health professional in accessible locations. This improves outcomes for patients and is also more cost effective. The development of a fully integrated sexual health service will deliver the desired improved outcomes of safe, effective, high quality, cost effective sexual health care to the population of Hywel Dda, utilising the principles of prudent healthcare. ALCOHOL AND SUBSTANCE MISUSE Our ambition, as a University Health Board is to work with our partners to achieve the following: Fewer adults and young people using drugs or drinking at levels / patterns that are damaging to themselves or others. Individuals able to recover from problematic drug and alcohol use and improve health, wellbeing and life chances through timely and evidenced based treatment and support services. The population we serve has access to information and education in order to highlight the risks and harms from alcohol misuse. A reduction in the impact to individuals and communities from anti social and criminal behaviour caused by drug and alcohol misuse. Actions Within this Strategic Objective, we have agreed one overarching action, and other individual actions: OVERALL Contribute to the development of partnership plans and the work which is on-going to identify priorities for Wellbeing which is being undertaken as part of the Wellbeing of Future Generations Act and Social Services & Wellbeing Act. SMOKING Performance manage the delivery of the tier 1 target through collating all service utilisation data, provide regular reports on performance and report on risks in terms of meeting these targets. Continue to meet with all smoking cessation service providers to review performance and address any operations issues. Work in partnership to ensure smoking cessation actions are included in all relevant Together for Health Delivery Plans. Work in partnership with the HDUHB Medicines Management Team to recruit and train Community Pharmacists to deliver the Level 3 Smoking Cessation Service as described in the Pharmacy Level 3 business case and the Welsh Government Primary Care Delivery Agreement (20/17). Work in partnership with the HDUHB Respiratory Team to manage the Hospital Smoking Cessation Service as described in the business case and the Welsh Government Primary Care Delivery Agreement (20/17). Work with Primary Care Lifestyle Advocates and Primary Care Clusters to ensure smoking cessation is supported in General Practice. Continue working with HDUHB midwifery teams to provide training in Brief Advice, Opt out Referral and using CO monitors as part of usual practice. Hywel Dda University Health Board Operational Plan 20/17 Page 12
Support the ongoing implementation and review of smoke free sites policy across HDUHB. Provide leadership for tobacco control across the HDUHB area through the implementation of the wider partnership Tobacco Control Action Plan. SEXUAL HEALTH Implementation of the HDUHB Sexual Health Services Strategy - To support the Business Case for the initial investment of 136,000 above the current operational costs to fully implement a safe, effective, high quality hub and spoke model of care for the future delivery of sexual health services and ensure the service is fully operational Developing a culture to support sexual health and wellbeing 1. Tackling inequity look at the whole population but focus effort on vulnerable groups and those with the greatest need 2. Involving users in decisions it is important that the service reflects the views of those who will be using it not just those on the delivery side 3. Providing good leadership Better prevention 4. Screening and vaccination cervical screening is delivered through the specialist service as well as through primary care and should not be forgotten in service planning 5. Access to information, advice and contraception Delivering modern sexual health services 6. Model of service delivery exploring the different ways that the service could be delivered in order to facilitate integrated practice and maximise benefit for users 7. Training/recruitment/retention staff are a vital resource and ensuring good quality training for central staff and wider stakeholders will improve and maintain the quality of service whilst encouraging recruitment and retention 8. Local Enhanced Services Primary care is essential to the delivery of sexual health services. There must be assurance that the service provided is safe and there is provision of adequate training Strengthening health intelligence and research 9. Need for ongoing monitoring of services and user needs any changes made to the service should be robustly evaluated 10. Need for better IT infrastructure this relates to capture and storage of data for clinical and surveillance purposes, and the basic infrastructure of the clinics including making appointments ALCOHOL AND SUBSTANCE MISUSE The specific actions we will take to support the achievement of these ambitions are as follows: Provide support for the further development and roll out of the Alcohol Liaison Nurse Scheme in secondary care settings in the UHB Provision of evidence based, good quality drug and alcohol services for patients with problematic drug and alcohol misuse Delivery of population wide alcohol awareness raising campaigns in order to raise awareness of the impact of excessive alcohol use on health and wellbeing, including raising awareness on new sensible drinking guidelines Delivery of targeted, age appropriate, alcohol and substance misuse awareness raising activities for children and young people in order to promote healthy lifestyle choices. Develop and monitor the implementation of the drug and alcohol misuse prevention plans and joint commissioning strategy Support development and implementation of alcohol and assault data project between partners in order to improve information sharing arrangements to reduce harm in the community Support and target further roll out of alcohol screening and brief interventions for staff across the Health Board and in community settings Establish, develop, implement and manage a robust process for the review of both fatal and non fatal overdoses Collaborate with the development of partnership plans and the work which is on-going to identify priorities for Wellbeing which is being undertaken as part of the Wellbeing of Future Generations Act and Social Services & Wellbeing Act. Hywel Dda University Health Board Operational Plan 20/17 Page 13
2 Overweight and Obesity To reduce overweight and obesity in our local population. Lead Executive Teresa Owen Lead Clinician Senior Responsible Officer Ian Scale Background Obesity is regarded as the most challenging public health priority of the 21st century. Within Hywel Dda with 58% of adults and 28% of children aged 4/5 being overweight or obese. For this latter infant age group the Carmarthenshire figure stands at 26.2%, Ceredigion at 28.7% and Pembrokeshire at 31%. The increasing prevalence of obesity makes it one of the main risks for shortened life expectancy and greatly increases the risk of type 2 diabetes, cardiovascular disease and some cancers. At a cost of 73m to the Welsh NHS (estimated at 8.4m to Hywel Dda), obesity places a significant burden on healthcare resources. (Trends/Trajectory to follow awaiting Public Health trend analysis by 20 th May 20). As a University Health Board, we aim to increase the proportion of children and adults at a healthy body weight and reduce the physical and mental health risks resulting from overweight and obesity. Ambition The first years of life set the scene for our lifelong health and well-being. Care for our infants during the first 1,000 days (including pre-conception and pregnancy) will have profound effect on life chances. Nutrition and mental health in particular, of babies, their parents and families are fundamental and being physical active is a key for development and avoidance of disease throughout our lives. Our ambition as a University Health Board is to work with our partners to turn the curve in the upward trend in individuals being overweight and to support families to give the next generation a greater chance of health. We want to see: A reduction in adult obesity by 0.5% by 2020 A reduction in childhood obesity by 1.0% by 2020 Parents working with us to eat healthily during pregnancy; Health Visitors, School Health Nurses, Midwives and other key professionals using 10 Steps to a Healthy Weight ; Actions Appropriate referrals to specialist weight management services; Work with our clinicians to ensure a holistic approach to overweight and obesity across the Four Levels of the Obesity Pathway Implementation Plan and integration with all Together for Health Delivery Plans. Our three year objectives are to: Work in collaboration with other partners of the public health system to develop, deliver and support existing programmes which aim to promote a healthy weight, especially in the first 1000 days (from conception to 2 years old pregnancy and early years). Continue to deliver the Early Years Obesity Prevention programme, as detailed in the Additional Funding for Primary Care Delivery Agreement. Continue to further develop the Lifestyle Advocates programme within primary care clusters. Develop and implement services for Obesity Pathway Level 2 and 3 for children and adults. Continue to work in partnership to support initiatives that increase physical activity and reduce sedentary behaviour. The next steps will be to meet with clinical colleagues to finalise aspirations, activity and plans within resource constraints. These plans will include a one-year Operational Plan with SMART objectives and trajectories for Year 2 and 3. Hywel Dda University Health Board Operational Plan 20/17 Page 14
3 Cardiovascular Disease To improve the prevention, detection and management of cardiovascular disease in the local population. Lead Executive Phil Kloer Lead Clinician Adrian Raybould Senior Responsible Officer Background Operational Element The prevalence of Cardiovascular Diseases, including Atrial Fibrillation in our population is increasing - over 20% of adults have high blood pressure and 9% have a heart condition (excluding high pressure). There are over 5,000 emergency admissions with a diagnosis relating to Cardiovascular Disease each year. We admit around 750 people a year with a stroke - a statistic which is remaining static. However, the number of people admitted to hospital with a stroke but who are still alive after 30 days is increasing. Over 57,000 people in Hywel Dda University Health Board (UHB) are listed on our GP Hypertension registers. 1,985 working days were lost to heart, cardiac and circulatory problems in our workforce in 2015/. Cardiovascular disease (CVD) is increasing and as it is strongly linked to age, given our ageing population it would be expected that CVD would also increase. The last Heart Disease Annual Report for the UHB shows CVD in those aged 85 around 29% in males and 20% in females. The proportion is much higher in males than in females for all age groups. As the number of people aged over 85 grows so will the number of people with CVD. Ambition Targets (from the IMTP) Hypertension - Increase the number of patients aged >50 who have had their blood pressure measured. Target 92%. Atrial Fibrillation - increase the number of patients diagnosed with Atrial Fibrillation who are on anticoagulation medication. Target 90%. Mortality - continuous improvement of 30 day mortality rate post event for Myocardial Infarction (MI) and stroke. Actions Work with Public Health Wales to understand expected incidence. Recruit and appoint atrial fibrillation and heart failure nurses in the community, and GP sessions to provide medical support. Establish discharge criteria having accessed specialist nursing services. Implement cardiology service model across all sites. Develop alternative service models for provision of anticoagulation for pharmacist led services based in community pharmacy and primary care. Hywel Dda University Health Board Operational Plan 20/17 Page 15
4 Cancer To increase survival rates for cancer through screening, earlier diagnosis, faster access to treatment and improved survivorship programmes. Lead Executives Joe Teape & Teresa Owen Lead Clinician Senior Responsible Officers Keith Jones (Ops) & Ian Scale (PH) Background Public Health Overview Cancer is a group of conditions where the body's cells begin to grow and reproduce in an uncontrollable way. There were 1,389 new cancers registered in Hywel Dda male residents in 2012, and 1226 in females. The European Aged Standardised Rate per 100,000 population was 463.0 for males and 396.6 for females. Across Wales, the rate of cancer in men is about 18% more than in women around 70 extra cases for every 100,000 men compared to the rate in women. Cancer is more common in men, although the incidence is declining, but increasing in women. (Trends/Trajectory to follow awaiting Public Health trend analysis by 20 th May 20). Anyone can get cancer and it has many causes, not all of them known. However the risk of developing cancer increases with age and contributing factors for some cancers are no longer in question. For example, the causal link between tobacco smoking and lung cancer is well known. Links between other carcinogens and some types of cancers are also established such as sun over-exposure and skin cancers and asbestos and mesothelioma (a rare cancer of the protective lining covering many internal organs). Air pollution is now known to be a risk for lung cancer (although, smoking remains the major problem). The types of cancers that are common (such as bowel, lung, breast and melanoma) further suggest that the way we live our lives is linked to their incidence. The main risk behaviours are smoking, alcohol drinking, physical inactivity, obesity and a poor diet, along with more sun and UV exposure with sunburns. Some viruses are also linked to certain types of cancer. The human papilloma virus (HPV) is the major cause of cervical cancer whilst the hepatitis B and C viruses can cause primary liver cancer. A small number of cancers are also hereditary, meaning they can run in families. Some types of cancer are more serious than others, some are more easily treated, and others have better survival rates. Many forms of cancer, especially if detected early enough, can be treated successfully, and mortality rates from cancer in the UK are decreasing. Operational Overview Hywel Dda University Health Board (UHB) provides medical services to 350,000 people in a largely rural area. As a whole the UHB has a slightly higher incidence of cancer than the Welsh mean. There are pockets of high economic deprivation associated with increased incidence of all types of cancer. The UHB supports diagnostic services and chemotherapy for most of the cancer sites. Oncology is supported by Abertawe Bro Morgannwg University Health Board (ABMUHB) and all radiotherapy takes place in Singleton or Velindre hospitals. Some specialist oncology surgery takes place in ABMUHB and Cardiff and Vale University Health Board (C&VUHB). Hywel Dda are working to reduce the cancer incidence further with a focus on reducing the health inequalities between the highest and the lowest socioeconomic groups. Delivering rapid, consistent, high quality and robust cancer services across 4 sites for small populations is a major challenge, particularly in view of changes in specialist clinical working and difficulties in recruiting specialist clinical staff to the UHB. Our major challenge is to overcome these difficulties to deliver a quality of service that is comparable to any in the U.K. To achieve this we will need to redesign services. Work on this is already taking place within our Acute Oncology Strategy Implementation Group and we are working closely with the South West Wales Cancer Centre (SWWCC) based at Singleton hospital to ensure that our services are fully integrated with our regional oncology provider. Cancer Incidence, Mortality and Survival We are using three outcome indicators to measure and track how well cancer services are doing over time. These are: Cancer incidence rate; Cancer mortality rate; One and five year survival rate. Outcome One Cancer incidence rate Hywel Dda has a slightly higher incidence of Cancer than the rest of Wales (Figure 1) although it is notable that the Hywel Dda University Health Board Operational Plan 20/17 Page
incidence of Cancer in Hywel Dda has reduced since 2012/2013. The incident rate is not equal across Hywel Dda - Ceredigion has the lowest incidence rate in Wales between 2009 and 2013 (WCISU, 2015). Figure 1 (Cancer Incidence) 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% Wales UK Hywel Dda 90.0% 89.0% 2010/11 2011/12 2012/13 2013/14 There is evidence that the incidence of cancer is higher in the most deprived areas of Wales. There are pockets of deprivation in Hywel Dda that are among the fifth most deprived areas in Wales. Outcome Two Cancer mortality rate The latest figures for Wales (to 2013) demonstrate that the mortality rate in Hywel Dda is comparable with Wales (Figure 2). Cancer incidence throughout Wales is increasing equally in male and females over the age of 85 years. Further work is required across Hywel Dda to project the potential increase in cancer incidence due to its aging population. Morbidity and Mortality rates / incidences are discussed monthly at each hospital site across the Health Board. Figure 2 (Mortality Rate) 200 150 100 50 0 Hywel Dda Wales Outcome Three One and five year survival rate This measure shows us how many people are alive one and five years after they have been diagnosed with cancer. Survival is likely to be longer if the disease is detected early, the person is in relatively good health and the treatment is effective. If our strategy is successful, over time, we would expect to see an increase in 1 and 5 year survival rates. The 1 and 5 year survival rate for cancer patients in Hywel Dda has increased and is comparable with the rest of Wales (Figure 3; Figure 4). Figure 3 (1 Year relative Cancer survival rates, all malignancies except non melanoma skin cancer) Hywel Dda University Health Board Operational Plan 20/17 Page 17
80 70 60 50 40 30 20 10 0 Hywel Dd a All Wales Figure 4 (5 Year relative Cancer survival rates, all malignancies except non melanoma skin cancer) 60 50 40 30 20 10 0 Hywel Dd a All Wales Ambition Public Health Element The University Health Board (UHB), with its partners, can help people avoid, recover from and survive cancer. Our services promote healthy living and screening for specific cancers. This may be through checking your own body (teeth, breast, testicles, skin, etc.) or attending for screening tests (diabetic eye screening, bowel, cervical etc). Early detection of problems when they arise gives the best chance of effective treatment and greater survival. Support for those suffering cancer can help make the journey more tolerable. This Strategic Aim encompasses a wide range of interventions. We want to see: More cancers avoided altogether. More cancers detected early. Effective services for treating cancers. Improved patient experience of support and treatment. Better survival. Our Strategic Aims as set out in our Integrated Medium Term Plan (IMTP) are to: increase the uptake of bowel screening by 5% by 2020; meet all Outcomes Framework referral and access targets; identify improved survival rate and experience targets; and increase rate of patients on end of life pathways including chosen place of death. Operational Element Our priorities for cancer are: Hywel Dda University Health Board Operational Plan 20/17 Page 18
Preventing cancer; Detecting cancer quickly; Delivering fast, effective treatment and care. Preventing Cancer (& Screening) Over the past 12 months we have: Promoted better public awareness risk factors. Reduced smoking, obesity and excess alcohol intake. Reduced the gap in inequalities in incidence and mortality rates for cancer. Worked collaboratively through the Cancer Networks. Encouraged participation in the programme of health checks for people aged over 50 to facilitate access to personally relevant, clear and consistent health advice. The Screening report produced by Public Health Wales outlines uptake for the year April 2013 to March 2014 (Figure 6). This demonstrates that the Health Board has achieved the national target for Breast screening. The Health Board has not met the national target for Bowel or Cervical screening although Bowel screening performance exceeds the Welsh average. Figure 6 2013/14 Reach Target Wales Hywel Dda Breast Women: 50 70 years every 3 years (over 70s can request) Bowel Men and Women: 60-74 years: every 2 years Cervical Women: (coverage) 25-50 years: every 3 years 50-64 years: every 5 years 70% minimum standard Carms. Cered. Pembs 72.1% 76.7% 79.6% 72.4% 73.2% 60% 52.6% 53.7% 54.1% 53.6% 53.1% 80% 78.4% 77.1% 77.5% 75.3% 77.5% Promoting uptake: Screening for Life campaign (Annual). This campaign was held for the first time in July 2013. In 2014, the campaign focused on working in low uptake areas. The July 2015 campaign aimed to maximise the use of social media, segmenting the audience to particularly target those that have never taken up an offer of screening previously (as evidence shows that once a person has attended for screening once, they are likely to continue to do so). Hywel Dda UHB Public Health Directorate has worked with Public Health Wales Screening Division and local groups to increase uptake of screening programmes. Particular activities have included: Events to engage with partners in health, community groups, third sector and wider stakeholders, around screening and tackling inequity; A project funded through the Welsh Government Health and Wellbeing Activity Grant wherein partners were engaged to hold conversations with community groups and previous screening service users about their experience. This particularly focussed on the uptake of bowel screening. Ceredigion: six Third Sector agencies being trained to hold over 300 conversations with service users Pembrokeshire: work through the Unity Project (traveller community) to hold conversations around screening invitations Carmarthenshire: focus groups to be held at the (over 50s) Add to Your Life event in Llanelli. Detecting Cancer Quickly Figure 8 below highlights that a higher percentage of Hywel Dda patients are diagnosed with early cancer in (Stage 1) than has been the case in previous years. This reflects the Health Board s priority focus on improving early diagnosis. It is also notable that the incidence of cancer diagnosis at stages 3 and 4 is reducing slightly. Figure 8: Stage of cancer diagnosis at presentation Hywel Dda University Health Board Operational Plan 20/17 Page 19