CARDIFF & VALE UHB RESPIRATORY DELIVERY PLAN

CARDIFF & VALE UHB RESPIRATORY DELIVERY PLAN 2014-2017 Final plan Sept 2014 1 P a g e

Together for Health: A Respiratory Health Delivery Plan. A Delivery Plan up to 2017 for the NHS and its partners. 1. INTRODUCTION The four Year NHS Plan, Together for Health, sets out the programme for health and healthcare in Wales and Together for Health A Respiratory Health Delivery Plan; A Delivery Plan up to 2017 for NHS Wales and its Partners forms part of a number of delivery plans for services areas. The plan sets out what is required for the delivery of measurable excellence in respiratory care services. This document provides the Cardiff and Vale implementation of this plan. 2. BACKGROUND AND CONTEXT The delivery plan sets out the Welsh Government s expectations of the NHS in Wales to tackle lung diseases in adults and young people wherever they live in Wales and whatever their circumstances. The Respiratory Health Delivery Plan sets out how the NHS will deliver on its responsibility to meet the needs of people at risk of developing, or affected by, a wide variety of acute and chronic lung conditions. This is a significant challenge, for individuals and their carers and the Welsh NHS. To sustain and continue developing high quality health care for the people of Wales, there needs to be increased levels of personal responsibility for lifestyle choices which influence people s risk of acquiring chronic conditions, or impacts the benefit of possible treatment. The Welsh Government issued a Public Health White Paper on 2 nd April 2014 to take forward our proposals to support improvements in lifestyle changes. The people of Wales need to fully engage in this debate if they are to help us achieve a healthier country, served by an effective and sustainable health service. This plan establishes: The population outcomes we expect The outcomes from NHS care we expect How success will be measured and the level of performance we expect Themes for action by the NHS, together with its partners Final plan Sept 2014 2 P a g e

The Vision: The Programme for Government states the overall population outcomes we want to achieve: better health for all and reduced inequalities in health. Reducing the impact of respiratory conditions on the lives of people in Wales will contribute significantly to these outcomes. For our population we want: 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. 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, 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 Final plan Sept 2014 3 P a g e

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. Local Health Boards need to focus their activity 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? This Delivery Plan establishes outcomes needed to improve respiratory health care in Wales. It sets out high level actions to support their effective delivery in the following areas: Preventing poor respiratory health People to be aware how to live healthy lifestyles, make healthy choices and minimise their risk of poor respiratory health and understand the consequences of not doing so Detecting respiratory disease quickly Respiratory disease to be detected quickly where it does occur Delivering fast, effective treatment and care People to receive prompt, effective treatment and care for their respiratory condition so that they have the best chance of optimising their quality of life and improving survival, reciprocated by patients taking treatment and care Supporting people living with lung disease People to be placed at the heart of respiratory health care with their individual needs identified and met so that they feel well supported, informed and able to manage the effects of poor lung health Improving Information Patients, health professionals and service planners will have access to appropriate information to help them make informed decisions about care and treatment. The public, the NHS, the third sector and the Welsh Government will have access to information on the outcomes of NHS Care Final plan Sept 2014 4 P a g e

Targeting research The Welsh Government and NHS Wales continue to promote the research base and ensure appropriate access to clinical trials which can lead to better outcomes for patients. 3. ORGANISATIONAL PROFILE Organisational Overview Cardiff and Vale University Health Board (UHB) is comprised of two acute district hospitals, the University Hospital of Wales (UHW) and the University Hospital of Llandough (UHL). In addition there are four hospitals providing medical and mental health inpatient beds. The UHW is the third largest University hospital in the UK and the UHB employs approximately 14,000 staff. The UHB acts as a tertiary unit from around Wales for many respiratory diseases; this increases the flow of patients through the organisation. Overview of Local Health Need and Challenge Demography Cardiff and Vale UHB area is the smallest and most densely populated Local Health Board area in Wales, primarily due to Wales capital city, Cardiff. The UHB covers less than 3% of the land area of Wales, but includes just under 15% of the population. Cardiff is one of the smaller local authorities in Wales in terms of area size but has the highest population density of 2,484 persons per square km (Source: Stats Wales 2012 estimate). The demographic profile of Cardiff differs from Wales due to the high number of young people resident in the area (figure 1). However, in the Vale of Glamorgan it is similar to the population of Wales (figure 2). Table 1 shows estimates of population numbers by age group and locality area. Final plan Sept 2014 5 P a g e

Figure 1 Figure 2 Proportion of population by age band, Cardiff and Wales, 2011 Produced by Public Health Wales Observatory, using Census 2011 (ONS) 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 05-09 00-04 Cardiff males Wales males Cardiff females Wales females 14 12 10 8 6 4 2 0 2 4 6 8 10 12 14 Proportion (%) of population Proportion of population by age band, The Vale of Glamorgan and Wales, 2011 Produced by Public Health Wales Observatory, using Census 2011 (ONS) 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 05-09 00-04 Vale males Wales females Vale females Wales males 14 12 10 8 6 4 2 0 2 4 6 8 10 12 14 Proportion (%) of population Table 1 Estimated population by age group, localities within Cardiff and Vale UHB area, 2011 Locality area All ages 0-4 5-15 16-64 65+ 85+ Vale of Glamorgan 126,700 7,400 16,400 79,700 23,200 3,200 Cardiff South, East and City 135,900 8,500 13,400 101,900 12,100 1,800 Cardiff North, West and South West 209,500 13,900 27,300 134,700 33,700 5,100 Total* 472,100 29,800 57,100 316,300 69,000 10,100 Produced by Public Health Wales Observatory, using MYE (ONS) *Totals may not match sum of locality data due to rounding The population of Cardiff and Vale is growing rapidly in size, projected to increase by 4% between 2013-17, significantly higher than the average growth across Wales. The population will pass 500,000 for the first time. It is important to highlight the predicted rise in the number of older people over the next 20 years. Projections suggest by 2030, the population of over 65 year olds will increase by 44% in Cardiff (19,710 people) and by 53% (12,480 people) in the Vale of Glamorgan. In particular, the numbers of the very elderly (85 yrs +) will increase markedly (10.4% increase between 2013-17). The increase in the number of older people is likely to cause a rise in chronic conditions such as circulatory and respiratory Final plan Sept 2014 6 P a g e

diseases and cancers. Meeting the needs of these individuals will be a key challenge for the UHB. In the current economic climate, the relative (and absolute) increase in economically dependent and, in some cases, care-dependent populations will pose particular challenges to communities. Black and minority ethnic populations Every NHS organisation has a statutory duty to promote race equality. Not only may ethnicity reflect specific language and cultural needs but also health needs. People from black and minority ethnic (BME) backgrounds are more likely to come from low income families, suffer poorer living conditions and gain lower levels of educational qualifications compared to white populations. In addition, certain BME groups have higher rates of some health conditions. For example, South Asian and Caribbeandescended populations have a substantially higher risk of diabetes; Bangladeshidescended populations are more likely to avoid alcohol but to smoke. [2] The 2011 Census shows that 15.3% of the population of Cardiff described themselves as non-white. In the Vale of Glamorgan this figure was 3.6%. The Welsh average was 4.4%. Inequalities Deprivation Deprivation is a wide concept that refers to the problems caused by a lack of resources and opportunities. The Welsh Index of Multiple Deprivation (WIMD) is the official measure of deprivation in small areas in Wales and measures the relative concentrations of deprivation at the small area level. In figure 3, the Lower Super Output Areas (LSOAs) in Cardiff and Vale of Glamorgan have been ranked and divided into fifths depending on their WIMD score. LSOAs in the most deprived fifth are coloured dark blue through to the least deprived fifth in light blue. This map shows clear higher levels of deprivation around the south of Cardiff and Barry. An area itself is not deprived: it is the circumstances and lifestyles of the people living there that affect its deprivation rank. It is important to remember that not everyone living in a deprived area is deprived and that not all deprived people live in deprived areas. Final plan Sept 2014 7 P a g e

Figure 3 Most health outcomes, including those for respiratory diseases which are highlighted in this needs assessment, are worse for lower socio-economic groups, indicating inequities in health outcomes. Inequities can also be apparent in access and use of health services. There is some evidence in the UK that lower socio-economic groups use preventative health services less and may have less access to secondary care except for emergency care. There is also some evidence that access and use of health services is less for ethnic minority groups. Data are currently being examined in Cardiff and Vale of Glamorgan on primary care risk factor management, and secondary care access, for conditions such as diabetes by socio-economic group. There is also potential to do this in the future for key respiratory disease indicators. Life expectancy Life expectancy in Cardiff and Vale, as in Wales in general, is increasing. In 2005-09 the average life expectancy in males was 77.3 (up from 76.1 in 2001-05) and 81.8 in females (up from 80.7 in 2001-05) (figure 4). However, this improvement is not experienced equally across all areas. The Slope Index of Inequality (SII) measures the absolute gap in years of life expected between the most and least deprived, taking into account the pattern across all fifths of deprivation within the UHB area. This shows Final plan Sept 2014 8 P a g e

there are substantial gaps in life expectancy between people living in the most and least deprived areas of the UHB area. There are even more stark differences in healthy life expectancy and disability-free life expectancy. For example in men, the gap in life expectancy between the most and least deprived fifths is more than 11 years, while the gap in healthy life expectancy is over 22 years. Moreover, these differences are increasing despite the overall improvement. Figure 4 Mortality The European age-standardised mortality rate for all respiratory diseases in Cardiff and Vale residents in 2011 was 79 per 100,000 (608 deaths), compared with 73 per 100,000 in Wales. This rate was second highest of all Health Boards in Wales, after Cwm Taf. Figure 5 shows the pattern for premature mortality (deaths under age 75) for respiratory disease in Cardiff and Vale residents between 2001-03 and 2008-10. Whilst the rate had decreased between 2002-05 and 2005-07, a gradual increase up to 2008-10 can be seen. The gap in respiratory mortality (all ages) between the least and most deprived between 2001 and 2009 can be seen for males (figure 6) and Final plan Sept 2014 9 P a g e

EASR per 100,000 females (figure 7) respectively. Mortality is much higher in the most deprived population, and for males the gap is widening. Figure 5 Mortality from respiratory disease, all persons under 75, European age-standardised rate (EASR) per 100,000, Cardiff & Vale UHB and Wales, 2001-03 to 2008-10 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS) Wales Cardiff & Vale UHB with 95% confidence interval 35 30 25 20 15 10 5 0 Average deaths per year in Cardiff & Vale UHB 129 128 122 107 104 111 117 125 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 Figure 6 Males Mortality from respiratory disease, all ages, males, European age-standardised rate (EASR) per 100,000, Cardiff and Vale UHB and Wales, 2001-09 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG) 180 160 140 120 100 80 60 40 20 0 Most deprived within Cardiff and Vale (95% CI) Wales EASR Least deprived within Cardiff and Vale Cardiff and Vale overall Rate Ratio - most deprived divided by least deprived 2.8 2.8 2.6 2.6 2.3 2.4 2.5 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 Final plan Sept 2014 10 P a g e

Figure 7 Females Mortality from respiratory disease, all ages, females, European age-standardised rate (EASR) per 100,000, Cardiff and Vale UHB and Wales, 2001-09 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG) 160 140 120 100 80 60 Most deprived within Cardiff and Vale (95% CI) Least deprived within Cardiff and Vale Wales EASR Cardiff and Vale overall 40 20 0 Rate Ratio - most deprived divided by least deprived 2.6 2.7 2.8 3.0 3.0 3.3 3.1 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 Morbidity The Welsh Health Survey (2011-2012) highlights that 13% of adults surveyed in Cardiff and Vale reported currently being treated for asthma, pleurisy, bronchitis or another respiratory illness. This is compared to 14% for Wales. Table 2 highlights the relative burden of recorded asthma and Chronic Obstructive Pulmonary Disease (COPD) in the nine neighbourhoods/areas of Cardiff and Vale, having taken age into account. Six point four percent of patients are on GP practice asthma registers, which is equivalent to the all Wales percentage. For COPD the figure is 1.2% in Cardiff and Vale which is lower than the all Wales figure of 1.4%. Table 3 highlights the actual numbers of patients with asthma and COPD on Cardiff and Vale GP practice registers in 2012, by GP cluster. Final plan Sept 2014 11 P a g e

Table 2 Age-standardised % of patients on selected chronic conditions registers, Cardiff & Vale UHB, 2012 Table 3 Number of patients on selected chronic condition registers, GP clusters in Cardiff and Vale UHB, 2012 Promotion of good respiratory health Smoking Smoking continues to be the largest single cause of ill health and premature death in Wales, and is a main cause of health inequalities, being a leading cause for the gap in life expectancy between rich and poor. The associated burden of illness has major costs for the NHS. It is a major contributory factor to the level of respiratory disease. Final plan Sept 2014 12 P a g e

Figure 8 shows that 21% of adults in Cardiff and Vale smoked in 2010-11, which together with Powys Health Board is the lowest percentage in Wales. Figure 8 Adults who smoke, 2010-2011 Age-standardised percentage, persons, age 16+, Wales health boards 95% confidence interval Wales = 23 Betsi Cadwaladr UHB 23 Powys thb 21 Hywel Dda HB 23 ABM UHB 23 Cardiff & Vale UHB 21 Cwm Taf UHB 26 Aneurin Bevan UHB 24 Figure 9 indicates that the percentage of smokers in the Cardiff and Vale population is gradually decreasing over time. Figure 9 30 Adults who reported currently being a current smoker, agestandardised percentage, Wales, Cardiff and the Vale of Glamorgan, 2003/04-2010/11 Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 25 20 15 10 5 0 2003/05 2004/06 2005/07 2007/08 2008/09 2009/10 2010/11 Wales The Vale of Glamorgan Cardiff However we can see from figures 10 and 11 that there is still much to be done to attain the Welsh government Tier 1 target for the number of smokers to be treated by smoking cessation services and the percentage of treated smokers who have quit at 4 weeks. Final plan Sept 2014 13 P a g e

Percentage of treated smokers Number of treated smokers Figure 10 Number of smokers treated annually across Cardiff and the Vale of Glamorgan by smoking cessation services 2006-2013 4500 4000 3500 3000 2500 2000 1500 1000 500 0 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 Tier 1 Target, 4088 SSW UHB Tier 1 Target Year Figure 11 Percentage of treated smokers C0 validated as having quit smoking at 4 weeks 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 40.0% Cardiff SSW Vale SSW Cardiff UHB Vale UHB Tier 1 Target Year Immunisation Immunisation against seasonal flu is a safe and effective intervention to reduce the risk of respiratory disease and complications in at-risk groups. Uptake of seasonal flu vaccine for recent seasons in Cardiff and Vale (with Wales comparator for the latest season) are shown in figure 12: Final plan Sept 2014 14 P a g e

Seasonal flu vaccine uptake 2012-13 % Seasonal flu vaccine uptake % Figure 12 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Over 65s Under 65s Year While steadily improving, uptake has not yet reached the 75% Tier 1 target on average for over 65s, and remains significantly below this level for under 65s at risk. Particular groups in the at risk category have especially low uptake (figure 13), including those with neurological disease and chronic liver disease. People with preexisting respiratory disease had uptake around 50%. For under 65s in at risk categories this leaves around 25,000 people unprotected by vaccination each year in Cardiff and Vale. Staff uptake of seasonal flu vaccination has increased significantly each year over the past few years but remains below the 50% Chief Medical Officer (CMO) target. Figure 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Condition Final plan Sept 2014 15 P a g e

Immunisation against pneumococcal disease is also offered in infancy and to people aged 65. Obesity Obesity is recognised as an important risk factor in the development of several respiratory diseases, for example obstructive sleep apnoea and the prevalence of symptoms associated with asthma such as wheezing and bronchial hyperresponsiveness. A summary of prevalence of, and trends in, obesity in Cardiff and Vale, the challenges we face, and action required by the UHB and partner organisations can be found in the Annual Report of the Director of Public Health for Cardiff and the Vale 2013 Obesity: the Bigger Picture. Hospital admissions In 2011 12 Cardiff and Vale UHB had the fifth highest emergency hospital admission rate for all respiratory diseases out of the 7 Health Boards. The age-standardised rate was 1,208 per 100,000 compared with 1,294 per 100,000 for Wales. Emergency hospital admissions (age-standardised) for asthma and COPD for the same period were as follows: Asthma: 87 per 100,000, compared with a Wales rate of 111 per 100,000 [378 emergency admissions] COPD: 137 per 100,000, compared with a Wales rate of 166 per 100,000 [782 emergency admissions] Health Board spend and respiratory health outcomes The NHS Expenditure and Health Tool highlights that Cardiff and Vale Health Board s expenditure on respiratory problems (using programme budget data) is less than other Health Boards but with relatively better respiratory-related outcomes and indicators than the rest of Wales: The Respiratory Unit within Cardiff and Vale Health Board also provides tertiary services for complex patients from around Wales such as those with interstitial lung diseases and neuromuscular ventilatory failure. Currently, these tertiary services do not receive specific funding but seek to provide care from within secondary care resources. Conclusions Final plan Sept 2014 16 P a g e

Whilst mortality from malignant cancers and circulatory disease has been decreasing, mortality from respiratory diseases has been rising slightly. Mortality from respiratory disease is much higher in our most deprived populations in Cardiff and Vale, and that gap is widening for men in particular. The pattern of ill health for asthma and COPD is highest in our most disadvantaged neighbourhoods/areas. Such patterning is also reflected in smoking rates and in obesity levels across our patch. Whilst progress has been made in decreasing smoking prevalence, there is still much to do. Our rates of emergency admissions for respiratory disease in Cardiff and Vale are lower than most Health Boards in Wales, which could partly be a reflection of good primary and community care, although there are generally multiple and complex reasons for the pattern of emergency hospital admissions. Whilst we appear to be delivering value for money in Cardiff and Vale with regard to spend compared with respiratory-related outcomes and indicators, we still have much to do to promote good respiratory health and prevent ill health, to detect ill health early and to support those with respiratory disease to live well with it, especially in our most disadvantaged communities. 4. DEVELOPMENT OF CARDIFF & VALE UHB RESPIRATORY PLAN A core team of multidisciplinary clinicians, managers and third sector patient organisations have been involved in the development of this delivery plan. This has enabled the plan to be clinically led, putting patients at the centre of our service development. The core team will also ensure the plans are integrated with our 3-year Integrated Medium Term Planning process. 5. PERFORMANCE MEASURES/MANAGEMENT The Welsh Government s Respiratory Plan contained an outline description of the national metrics that LHBs and other organisations will publish: Outcome indicators which will demonstrate success in delivering positive changes in outcomes for the population of Wales. National performance measures which will quantify an organisation s progress with implementing key areas of the Delivery Plan. Progress with these outcome indicators will form the basis of our annual respiratory plan report. The first Annual Report will be produced in March 2015 as per Welsh Government requirements. Final plan Sept 2014 17 P a g e

Review of milestone for achievement will be part of our core performance review procedures. 6. ACTION PLAN The following table sets out the detailed action plan for Cardiff & Vale UHB. Whilst each of the 8 themes has specific actions, there is linkage between them premised on consistency in relation to high quality and disease stage appropriate - (prevention and diagnosis through to end of life) - information, self-management, education, lifestyle, diet/nutrition, exercise and advice support; recognising that the rôle for patient groups within this context needs to be explored. Where there are indications for development of standardised documentation/formatting the aim would be for this to be replicable across conditions. Final plan Sept 2014 18 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 EXPECTED OUTCOMES 1. PREVENTING RESPIRATORY DISEASE Leads : Trina Nealon, Nuala Mahon 1a. SMOKING Lead : Trina Nealon, with: Guy Marshall, Karen May, Chris Mulholland Delivery of the tobacco action plan for 2014-15 Delivery of tobacco action plan: 1. Work with a broad range of partners (including community pharmacists, GPs, secondary care, Local Government and the third sector) to deliver local strategies and services to prevent smoking, offer support for those wishing to quit, and achieve the Tier 1 target on smoking cessation 2. Work together to regularly review, plan and deliver the smoking cessation programmes recommended in the Tobacco Control Action Plan for Wales (2011) ensuring appropriate data collection for monitoring success 1. Delivery of annual tobacco action plan 2. All Primary Health Care Teams (PHCTs) should be encouraged to adopt the Smoking Pathway to encourage identification & referral of smoker to Stop Smoking Wales (SSW); improve in house smoking cessation services if provided and ensure relevant training has occurred. This can be part of each Cluster Plan for the ongoing Local Service Development work in Primary Care 1. Reduction in the prevalence of adult smoking to 20% by 2016 and 16% by 2020 2. Aim for 100% adoption of pathway end of year 2015/16 3. Ensure smoking cessation services comply with best practice 4. Ensure sufficient capacity and workforce to be able to deliver the actions and outcomes of the Tobacco Control Action Plan for Wales (2011) GUIDELINES FOR GP PRACTICE DEVELOPM 3. All PHCT s should be encouraged to refer electronically to SSW (similar process to other secondary care referrals). 3. Aim for >80% referrals to SSW to be made electronically by March 2016 19 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 EXPECTED OUTCOMES 1b.VACCINATION PROGRAMME Ensure >75% of target populations receive appropriate vaccinations Lead: Nuala Mahon with Guy Marshall, Michelle Treasure 1. Increase vaccination against seasonal flu among eligible members of the public, particularly among under 65s in at risk groups (a set of detailed actions is described in the C&V seasonal flu action plan) 2. Increase vaccination rates among frontline C&V staff to over 50% (see seasonal flu action plan) 1. Continue actions to raise seasonal flu vaccination, described in current action plan which covers not only the season itself but the whole year, and is refreshed on a regular basis, reporting to C&V Immunisation Steering Group, through targeted planning/intervention by PHCTs in their Cluster Plans 1 Uptake >75% over 65s 2 Increase in uptake >5% each year among under 65s 3 Uptake >50% among frontline healthcare staff 2. DETECTING LUNG DISEASE EARLY Lead: Dr. Guy Marshall, with: Michelle Treasure, Karen May Ensure that all staff involved in the performance and interpretation of spirometry are trained and assessed to ARTP standards or equivalent. Primary care to work closely with smoking cessation services and SSW to try and improve success rates. Work closely with other agencies such as the 1. All smokers to be offered advice, treatment and/or directed toward a smoking cessation service. 2. Ensure primary care work closely with SSW 3. Ensure links with BLF are made to enable patients to access support and advice 1. Train staff who need to be upskilled to ARTP standard 2. Coordinate evidence of PHCT staff training in spirometry 3. Develop locality lead nurse or focus group to co-ordinate the spirometry service and enable consistency in training and equipment provision. 1 People over-35 who smoke are offered spirometry and signposted to smoking cessation support and made aware of the consequences of continuing to smoke on their health and possible future treatment 2 At-risk groups who present with persistent 20 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 BLF and facilitate patients to access such services for support and advice. Encourage a rapid referral for spirometry testing in those at-risk patients who repeatedly present in primary care with respiratory problems. EXPECTED OUTCOMES respiratory symptoms receive appropriate diagnostic tests and are signposted to support and treatment as required Primary Care to liaise closely with secondary care and CRRU to facilitate a safe discharge and follow up. 3 DELIVERING FAST, EFFECTIVE CARE Leads : Dr Katie Pink, Ramsay Sabit, Ben Hope Gill, Aneurin Buttress, Simon Barry 3.a ASTHMA & ALLERGY Lead: Dr. Katie Pink, with : Michelle Treasure, Karen May, Mari Lea-Davies, Jane Mullins, Paul Williams, Guy Marshall Deliver High impact change for people with Asthma and allergies To ensure patients receive a timely and 1. Reinforce use and uptake of the prescribing algorithm to guide product choice and embed key prescribing messages re: stepping down therapy when appropriate 2. Healthcare professionals in primary 1. Ongoing education of health care professionals in regard to the prescribing algorithm/inhaler technique with specific targeting of practices/areas as required. 1 Continued reduction in % of high dose inhaled corticosteroid prescriptions 2 Reduction in the 21 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 accurate diagnosis To ensure asthma is managed according to local and national guidelines To ensure patients receive a comprehensive asthma review including education, inhaler technique, concordance and an action plan. To develop a comprehensive secondary care service to assess and treat difficult asthma To improve the management of acute asthma including follow-up after unscheduled health care visits To develop a national care to be able to access training annually to ensure patients can use the device they are prescribed 3. Appoint a full time respiratory physician with an interest in asthma 4. Audit into management of acute asthma in ED with a view to developing an admission pathway and formalised discharge bundle 5. Develop the Welsh national difficult asthma group to allow MDT discussion of patients with difficult symptoms and address provision of tertiary level services in Wales/ referral pathways for specialist services only provided in England (e.g. thermoplasty) 2. Develop a formalised patient referral process to asthma Cymru for Asthma 3. All patients to be given a written asthma plan as part of their annual review training to be provided to practice nurses - this should be a UHB wide developed and adopted document 4. Work with primary care to develop systems to ensure follow-up of patients admitted with an acute exacerbation asthma as part of an agreed UHB wide discharge bundle/pathway for secondary and primary care 5. Explore with secondary care pharmacy team the possibility of teaching inhaler technique on issue of all new inhalers 6. Encourage community pharmacists to teach inhaler technique with all respiratory focused medicines use reviews EXPECTED OUTCOMES number of practices within C&V who do not demonstrate a year-on year reduction in outcome 1. 3 Reduction in unscheduled health care utilisation 4 Reduction in asthma mortality 5 Increase in number of patients with a self management plan in place 22 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 difficult asthma network in conjunction with other LHBs/clinicians in Wales 7. Develop a business case to fund and develop the role of an asthma specialist nurse. 8. Explore the potential to develop a quick access respiratory service for acute difficult patients. EXPECTED OUTCOMES 9. Develop a plan to establish referral pathways with allied professionals ENT/ Speech therapy/ psychology/ allergy. Resourcing requirements to be included in a business plan. 10. Decrease waiting times in lung function laboratory to provide acceptable RTT for core services, modelling in requirements for service developments that will require additional lung function laboratory services. 11. Develop a multidisciplinary workforce plan including respiratory physiology, physiotherapy and psychology as well as medical and nursing requirements. 23 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 EXPECTED OUTCOMES 12. Develop a formalised discharge bundle covering the patients journey from secondary to primary care with a nominated lead of all Lead GPs/Nurses in each PHCT 3.b CHRONIC OBSTRUCTIVE PULMONARY DISEASE(COPD) and BRONCHIECTASIS Lead: Dr Ramsay Sabit, with: Jamie Duckers, Trina Nealon, Tom Lines, Mari Lea-Davies, Karen May, Paul Thomas Deliver High impact change for people with COPD and Bronchiectasis Provide evidencebased high quality treatment for patients with COPD and Bronchiectasis based on National Guidelines Ensure seamless provision of care for patients with COPD and Bronchiectasis across the primary secondary care interface 1. Use the prescribing algorithm to guide product choice and embed key prescribing messages 2. Provide MDT input for complex COPD patients across a seamless primary /secondary care interface 3. Offer patients with COPD or bronchiectasis written information on their condition 4. Formulation of dedicated protocols for antibiotic treatment for bronchiectasis (written in conjunction with microbiology) 5. CRRU service to continue to provide community support to patients 1. Set up a difficult COPD clinic which caters for end stage patients and frequent exacerbators 2. Provide a fast track pulmonary rehabilitation assessment and intervention service for eligible patients with COPD and bronchiectasis) who have been discharged from hospital 3. Offer eligible patients with COPD written self management plans on the management of their condition (including management of exacerbations) 1. All eligible patients with COPD will be provided with written action plans regarding the management of their condition (including the management of exacerbations) 2. All bronchiectasis patients to have individualised airways clearance assessment by a specialist respiratory physiotherapist 24 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 Offer patients with COPD and bronchiectasis the opportunity to learn more about the condition and how to manage diagnosed with COPD, with access to/for GPs to avoid inappropriate admission 6. Develop standardised C&V UHB format for self-management/action plans 4. Offer standardised information on general management of COPD accessed for both primary and secondary care including disease physiology, breathlessness management, exercise, psychological impact and management, pharmacological management using H.E.L.P framework used in CRRU EXPECTED OUTCOMES 3. All bronchiectasis patients to have a self management plan 4. Repeat audit against BTS standards of care for bronchiectasis patients 5. Establish H.E.L.P framework training programme for locality leads 6. Set up an endobronchial valve intervention MDT 7. Use of Hypotonic Saline Challenge test service to reduce chest infections in bronchiectasis patients 8. Run Welsh Specialist Interest Group for bronchiectasis 9. Improved links with primary care and acute response team and development of lead specialist nurse for 25 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 bronchiectasis within acute team EXPECTED OUTCOMES 10. Develop a formalised discharge bundle covering the patients journey from secondary to primary care with a nominated lead of all Lead GPs/Nurses in each PHCT 3.c INTERSTITIAL LUNG DISEASES (ILDs). Lead Dr. Ben Hope Gill with: Julie Hocking, Haydn Adams, Tom Hockey Deliver High impact change for people with ILDs Develop a national plan for ILD with other LHBs and WHSSC 1. Agree funding for the agreed national ILD service with other LHBs and WHSSC. 2. Establish weekly ILD MDT following commissioning by WHSSC. 3. Improve access to ILD specialist nurse support and respiratory physiology requirements 4. Provide an educational programme on ILD and bronchiectasis in particular for primary care to improve awareness, diagnosis, referral etc 1. Provide written information to all patients with ILD -2015. 2. Provide integrated pathways including palliative care and pulmonary rehabilitation 2015. 1. All people diagnosed with ILD to be managed through MDT that works to newly developed national guideline 2. All patients with ILD to have appropriate access to ILD specialist nurse support. 5. Consider appointment of thoracic radiologist- required for ILD MDT. 26 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 EXPECTED OUTCOMES 3.d SLEEP DISORDERED BREATHING (SDB) Lead: Dr Aneurin Buttress with : Beverly Ooss, Helen Nicholls, Mari Lea-Davies, Paul Thomas Deliver High impact change for people with Sleep Disordered Breathing 1 To decrease and maintain referral time providing care within RTT for all patients. 2 Develop a single referral pathway for patients with suspected SDB. 3 Review Lung Function Laboratory capacity to support OSA service including the CPAP ventilation machines 1 Annual review for those patients with vigilance specific occupation. 2 Develop a sleep laboratory for the diagnosis and management of patient s with sleep disordered breathing (SDB). 3 Offer those diagnosed with SDB secondary to obesity referral to dietetics and a graded exercise program. 4 Work with colleagues, public health and primary care to develop an integrated approach to OSA/metabolic syndrome 5 Integrate with clinic psychology develop treatment pathway for those patients with insomnia 6 Develop a regional MDT for complex sleep disorders 1 Rapid investigation and diagnosis of SDB. 2 Reduction in GP attendances and hospital referrals to other specialties through undiagnosed and untreated SDB. 3 Improve diagnosis and treatment of patients with SDB avoiding delay (e.g. referring to ENT) and duplication of investigation providing a clear referral pathway for patients and primary care 4 Monthly MDT involving regional sleep consultants 27 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 EXPECTED OUTCOMES and sleep physiologists improving management of complex sleep disorders 5 Improve health outcomes for patients diagnosed with OSA/metabolic syndrome 3e ACUTE RESPIRATORY ILLNESS Lead: Dr Simon Barry, with: Ceri Gambold, Mari Lea-Davies, Karen May, Paul Thomas Deliver High impact change for people with acute respiratory illness 1. Review Lung Function Laboratory capacity to support acute respiratory illness. 2. Ensure communication of Respiratory Physiology tips in acutely ill respiratory patients 1 Develop emergency protocols for acute asthma treatment, for acute life threatening asthma attacks. 6 Develop diagnostic and treatment pathways for patients with insomnia To be completed by June 2015 3. Agree an antibiotic prescribing policy covering primary and secondary care 28 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 to promote prudent, appropriate prescribing EXPECTED OUTCOMES 4 DELIVERING FAST, EFFECTIVE CARE Leads: Lead Jamie Duckers, Guy Marshall, Ceri Gambold, Mel Jefferson 4a SELF-MANAGEMENT PLAN Lead Jamie Duckers, with: Ceri Gambold, Ramsay Sabit, Aneurin Buttress, Anthony Byrne, Chris Mulholland Strengthen selfmanagement of those with lung disease 1 To survey the information that patients with chronic respiratory disease are given from primary care and secondary care. 2 To survey the use of self management plans given to patients in primary and secondary care and where patients are accessing healthcare advice/consultation i.e. To analyse the patient journey between primary/ secondary care 3 To survey what patients with chronic respiratory disease would like in terms of education and self management plans (contacted British Lung Foundation for patient representatives) 1 Standardise self-management plans 2 Ensure that all people with chronic respiratory conditions have a personalised written self-management plan in place within three months of diagnosis (Written information regarding patients chronic lung disease offered at diagnosis and links to National websites and patient support groups ) with a copy to the patient and the GP. 3 Consider use of patient passport to support self management plans for each condition from secondary care. 1 Ensure that all people with chronic respiratory conditions have a personalised selfmanagement plan in place within three months of diagnosis 29 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 EXPECTED OUTCOMES 4 Ensure availability of information to support self-management e.g. BLF leaflets 4 Audit the use of self management plans in bronchiectasis and COPD (audit of bronchiectasis patients just completed) 5 Ensure all patients are offered the opportunity to have a selfmanagement plan within 3 months of diagnosis 6 Audit use of self management plan 4b ANNUAL MEASUREMENT Ensure that all respiratory patients have the necessary key measurements taken annually to identify early decline in disease and facilitate appropriate interventions 4c REFERRAL TO PATIENT GROUPS Lead: Guy Marshall, with: Michelle Treasure 1. Develop local guideline for undertaking annual reviews in line with national guidance 2. Ensuring staff are appropriately trained in spirometry and FEV1 monitoring. 7 Design information / contact pack condition specific for chronic respiratory patients 1. Annual reviews to be performed according to local and national guidelines 2. At least one member of staff in each primary care practice to be trained to an ARTP level or equivalent. Lead: Ceri Gambold with: Chris Mulholland 1. Reduced exacerbations and hospital admissions by ensuring HCP in primary care are identifying early decline in respiratory patients 30 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 Support the development of, and encourage referral to, patient groups such as Breathe Easy 1. Map existing groups and sources of referral 2. Improve dissemination of information regarding existing groups 3. Review with the third sector the way that patient groups are run to maximize their impact across the whole pathway 1. BLF Breath Easy group only in Cardiff area, explore feasibility of further group serving the Vale of Glamorgan. 2. Engage with Health care professionals in primary care to help with support development of existing groups to encourage participation of patients at an earlier stage of disease pathway and include those that are not seen in secondary care. EXPECTED OUTCOMES 1. Support individuals with respiratory conditions offer training in techniques which build self-sufficiency 2. Increase in number of referrals to self support groups 3. Review and present a proposal for patients groups and their management to maximise their impact. Implementation in 2015-16 4d ACCESS TO PALLIATIVE CARE SERVICES AND END OF LIFE RESPITE CARE Lead: Dr Mel Jefferson with Mel Lewis Patients with advanced disease need prompt access to effective palliative end of life care as set out in the Cardiff and Vale UHB End of Life Delivery Plan. 1. Monitor implementation of end of life delivery plan in relation to respiratory patients 1. Ensure needs of respiratory patients are included in the annual end of life plan 2. Encourage primary and secondary care to use the "surprise question" (Gold standards Framework) to 1. Ensure adequate and equitable access to palliative care services including respite care, for patients with respiratory disease in the end 31 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 identify palliative care patients; encourage use of CRU nurses alongside pall care teams; encourage CRU nurses to attend primary care MDT meetings where appropriate EXPECTED OUTCOMES stages of their illness 3. In line with C&V UHB End of Life Care Plan, work with specialist palliative care services to improve communication skills of health professionals and social care teams to encourage discussion with patients regarding advanced decision making and end of life care plans 4e ACCESS TO NERS SCHEME Lead: Guy Marshall with Tom Lines Utilise appropriate referral to the NERS scheme to support people with respiratory conditions increase their long-term adherence to physical activity 5. IMPROVING INFORMATION 1. Ensure that all HCP in primary care are familiar with the referral process to NERS and providing all referrers with appropriate updates and documentation. 1. All respiratory patients who are deemed suitable for the NERS scheme have a documented offer of referral to NERS. 2. Liaise with local authorities regarding staff training in Leisure centres 1. Ensure appropriate referral to, and uptake of, NERS scheme for people with respiratory conditions to promote physical activity as part of self-management plans 32 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 Leads Fiona Kinghorn, Andrew Nelson, Clinical Lead Respiratory Delivery group EXPECTED OUTCOMES 5a. RECORD AND USE INFORMATION Lead Fiona Kinghorn Record and use information provided by Public Health Wales and WG sources to guide review and development of services 1. Use stats Wales data and other sources to inform delivery plan and IMTP 2. Use stats Wales data and other sources to inform annual report 1. Use stats Wales data and other sources to inform delivery plan and IMTP 2. Use stats Wales data and other sources to inform annual report 1. Use of up to date data to inform planning 5b. OUTCOME DATA Lead Andrew Nelson Ensure high quality transfer of data between primary and secondary care outcome data thus ensuring that information is of highquality and supports optimal levels of care for patients Information from local and primary care services are collected and used to facilitate development and transparently published 1. Request to the national delivery group to progress this on an all Wales basis: To prioritise the need for IT systems to interconnect to support better information flows between primary and secondary care to support outcome measurement collection 2. E discharge from hospital to GPs To be determined during 2014 1. Data systems that safely transfer patient data electronically in real time with an expansion on what is currently available 2. Use of outcome data to drive improvement and benchmarking 3. Clinicians should provide clear and thorough notes and timely transfer of care information 33 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 EXPECTED OUTCOMES 5c DATA FOR ANNUAL REPORT Lead Andrew Nelson To use data and information collected so as to reflect service provision and outcomes and to report such progress annually 1. Develop a performance report to inform quarterly, 6 monthly and annual report To be determined during 2014 1. Accurate timely data in reports 5d DELIVERY PLAN PROGRESS LEAD Clinical Lead Respiratory Delivery group Report progress against local delivery plan milestones on their website 1. Quarterly review of progress 2. 6 monthly updates on UHB website 1. Annual report September 2015 Annual report and updates delivered on time 6. TARGETING RESEARCH Leads Dr Simon Barry, Guy Marshall, Nichola Gale 6a PROMOTE RESEARCH & COLLABORATION To promote an environment to develop R&D To promote and facilitate good communication and collaboration between multi-institutional 1. Publications- pulmonary rehab in non cystic fibrosis& bronchiectasis 2. Collaborations with Marie Curie Palliative Care Research Centre at Cardiff University to develop studies in relation to patient and carer supportive, as well as palliative needs and symptom control in conditions such as Leads Dr Simon Barry and Dr Guy Marshall 1. Organise a respiratory research meeting to bring together clinicians, academics and students, through Cardiff Chest Federation and the Respiratory Research network 2. Consider whether t 1 above could formally become a 1. An increased number of respiratory trials run within Wales 2. Increased collaboration between researchers in 34 P a g e

OBJECTIVES ACTIONS 2014-15 PROPOSED ACTIONS 2015-16, 2016-17 research groups in Wales IPF. 3. Collaborations with Cardiff University, industry, primary and secondary care e.g. ARCADE study network accessible to primary care as well OR whether the UHB should develop a primary care network 3. Develop a registry of ongoing studies in C&V with a view to rolling out across Wales via WTS EXPECTED OUTCOMES Wales 6b RESEARCH TRIALS Lead Dr Nichola Gale Cardiff University To enable groups of respiratory researchers across Wales to contribute to and/or initiate: Major UK-wide trials funded by major grantawarding bodies (e.g. MRC, Welcome Trust, NIHR etc) 1. Promote research activity and potential benefits to patients and clinicians 2. Encourage clinicians as co-applicants on grants and sponsored research, to allow 3. Easier access to patients & R&D approvals. 1. Build a registry and shared database of patients interested in participating in research 2. Showcase successful ongoing research 1. Increase research activity at local and national levels Multicentre clinical trials sponsored by pharmaceutical companies via the 35 P a g e