2014/15 ANNUAL REPORT OF THE POWYS HEART DISEASE DELIVERY PLAN. Director of Public Health. Director of Public Health

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1 BOARD MEETING 21 OCTOBER 2015 AGENDA ITEM /15 ANNUAL REPORT OF THE POWYS HEART DISEASE DELIVERY PLAN Report of Director of Public Health Paper prepared by Director of Public Health Principal Health Promotion Specialist (on secondment to the Powys Public Health Team) Purpose of Paper To present the Powys Heart Disease Delivery Plan for approval Action/Decision required To note and approve the Link to Doing Well, Doing Better: Standards for Health Services in Wales : Link to Health Board s Corporate Plan This report particularly supports Standards 3, 6 and 7 Improving Health and Well-Being Ensuring the Right Access Striving for Excellence Acronyms and abbreviations Fully listed in the Report Page 1 of 41

2 2014/15 ANNUAL REPORT OF THE POWYS HEART DISEASE DELIVERY PLAN Background The Powys Teaching Health Board Heart Disease Delivery Plan (HDDP) was approved by Board in February The Plan included a detailed needs assessment and a plan for national and local priorities, structured around the six themes, as specified by Welsh Government: 1. The Promotion of Healthy Hearts 2. The Timely Detection of Heart Disease 3. Fast and Effective Care 4. Living with Heart Disease 5. Improving Information 6. Targeting Research Routine progress update reports were subsequently submitted, as required, to Welsh Government in May and December At Powys Teaching Health Board Executive level, progress has been noted in a number of areas, along with some challenges to delivery going forward. For example, the Powys Teaching Health Board HDDP does not yet have a lead officer or a clinical lead for local delivery of the HDDP. This is the first annual report of the Powys Teaching Health Board HDDP and focuses on the position and progress made during 2014/15. The intelligence presented in the report was produced and provided by Welsh Government or Public Health Wales for local use and commentary in the HDDP Annual Report; however, not all analyses are available at Powys Teaching Health Board level. The analyses provided relate either to cardiovascular disease (CVD) or to coronary heart disease. The Annual Report is structured as follows: 1 Executive Summary 2 Introduction and Background 3 Overview of the Burden of Heart Disease Mortality 4 Outcome Indicators i. Prevalence Rates ii. Emergency Admissions for Cardiovascular Disease iii. Mortality from Cardiovascular Disease iv. Mortality within 30 Days of a Myocardial Infarction 5 The Prevention and Management of Heart Disease i. The Promotion of Healthy Hearts ii. The Timely Detection of Heart Disease iii. Fast and Effective Care iv. Living with Heart Disease v. Improving Information vi. Targeting Research 6 Looking Forward Page 2 of 41

3 Conclusions As highlighted in the report, particular features include that: Further evidence has emerged that the age adjusted prevalence of coronary heart disease is significantly lower (better) in Powys than the rest of Wales Powys has the lowest (best) age-standardised emergency admission rate for CVD in Wales, significantly lower than the Wales average As is the case nationally, age-standardised mortality rates from CVD have been falling in Powys since at least 2004; rates in Powys have tended to be statistically significantly lower (better) than Wales as a whole During the period 2011 to 2013, the premature mortality rate from CHD in Powys was the lowest (best) of all Health Boards and was statistically significantly lower (better) than the all-wales rate During the period 2009 to 2013, there was some variation in CVD premature mortality rates within Powys - but no area had a significantly higher (worse) rate than Wales and seven areas experienced rates which were significantly lower (better) than the Wales average Examples of progress made during 2014/15 include: As part of its Tobacco Control Action Plan: development of the Powys Teaching Health Board Smoke Free Policy (which will be presented to Board for approval later in 2015/16) Implementation of Local Enhanced Service agreements with Powys general practices, to improve the prevention and management of cardiovascular disease, including heart failure and diabetes A range of other developments in the provision of community based services for patients with heart disease, including heart failure The development of commissioning arrangements (including through clearer commissioning intentions) which support delivery of the Powys Teaching Health Board HDDP. This encompasses improvements in commissioning and monitoring arrangements around cardiac diagnostics (from February 2015) Recommendation To note and approve the Powys Heart Disease Delivery Plan Page 3 of 41

4 Report prepared by: Name Dr Catherine Woodward Director of Public Health Presented By: Name Dr Catherine Woodward Director of Public Health Ms Jennifer Evans Principal Health Promotion Specialist Public Health Wales (on secondment) Background Papers Financial Consequences Other Resource Implications Consultees National HDDP; Powys Teaching Health Board HDDP None specific None specific None specific Page 4 of 41

5 Powys Teaching Health Board Heart Disease Delivery Plan 2014/15 Annual Report Page 5 of 41

6 Abbreviations and Acronyms AWMGS BAFTA BMI CHD CABG CI CVD DNACPR EASR HDDP MI MSOA MYE NERS NHS NWIS ONS PEDW PCI PHM PTHB RTT SAIL SSW T&F USOA WAST WG WHS WHSSC WIMD QOF All Wales Medical Genetics Service Birmingham Atrial Fibrillation Treatment of the Aged Body Mass Index Coronary heart disease Coronary artery bypass graft Confidence interval Cardiovascular disease Do Not Attempt Cardiopulmonary Resuscitation European Age-standardised Rate Heart Disease Delivery Plan Myocardial infarction Middle Super Output Area Mid-Year Population Estimate National exercise referral scheme National Health Service NHS Wales Informatics Service Office for National Statistics Patient Episode Database for Wales Percutaneous coronary intervention Public health mortality Powys Teaching Health Board Referral to treatment Secure Anonymised Information Linkage Stop Smoking Wales Task and Finish Upper Super Output Area Welsh Ambulance Service Trust Welsh Government Welsh Health Survey Welsh Health Specialised Services Committee Welsh Index of Multiple Deprivation Quality and Outcomes Framework Page 6 of 41

7 1. Executive Summary The PTHB Heart Disease Delivery Plan (HDDP) was approved by Board in February This is the first annual report of the PTHB HDDP and focuses on progress made during 2014/15. The PTHB HDDP supports the vision for heart care in Wales, which is for: People of all ages to have as low as possible a risk of developing heart disease and an excellent chance of living a long and healthy life Wales to have incidence, mortality and survival rates for heart disease which are comparable with the best in Europe PTHB has a responsibility to ensure local delivery of the national HDDP, in both its NHS provider and commissioner roles. The PTHB HDDP is one of a number of Welsh Government Delivery Plans that were included in the Health Board s Integrated Medium Term Plan 2015/18, designed around the vision set out by the Board to achieve truly integrated care centred on the needs of the individual. The PTHB HDDP action plan is tracked by the Executive Team. Progress for 2014/15 has been noted in a number of areas, along with challenges to delivery going forward - many of which are common to the local delivery of the range of other Together for Health plans. Key achievements and progress for the HDDP during 2014/15 included: As part of its Tobacco Control Action Plan: development of the PTHB Smoke Free Policy Further development of referral pathways to smoking cessation services (PHW Stop Smoking Wales (SSW) and the local Level 3 pharmacy services) Training delivered to PTHB health visitors around Smoke Free homes Implementation of Local Enhanced Service agreements with Powys general practices, to improve the prevention and management of cardiovascular disease, including heart failure and diabetes A range of other developments in the provision of community based services for patients with heart disease, including heart failure The development of commissioning arrangements (including through clearer commissioning intentions) which support delivery of the PTHB HDDP. This encompasses improvements in commissioning and monitoring arrangements around cardiac diagnostics (from February 2015) Improvements in local cardiology provision, including repatriation of OP activity and cardiac investigation Page 7 of 41

8 2. Introduction and Background Welsh Government launched Together for Health: A Heart Disease Delivery Plan (HDDP) in May 2013 and provided a framework for action by Local Health Boards and NHS Trusts working together with their partners. The Plan set out Welsh Government expectations of the NHS in Wales to prevent avoidable heart disease and to plan, secure and deliver high quality, person-centred care for people at risk of or affected by heart disease. The Plan focused on meeting population need, tackling variation in access to services and reducing inequalities in health outcomes, across six themes: 7. The promotion of healthy hearts 8. The timely detection of heart disease 9. Fast and effective care 10. Living with heart disease 11. Improving information 12. Targeting research More broadly, the vision for heart care in Wales is for: People of all ages to have as low as possible a risk of developing heart disease and an excellent chance of living a long and healthy life Wales to have incidence, mortality and survival rates for heart disease which are comparable with the best in Europe For each of the six themes, the national HDDP set out: Delivery aspirations for the prevention and treatment of heart disease Specific priorities for delivery during the period 2013/14 to 2015/16 A responsibility to develop and deliver actions to achieve the specific priorities Population outcome indicators and NHS assurance measures The HDDP is one of a broad suite of plans supporting Together for Health, the Government s five year vision for the NHS in Wales. Following publication of the HDDP, all Health Boards were required to develop and agree detailed local HDDPs, for submission to Welsh Government by December The PTHB HDDP for Powys was submitted to Welsh Government in advance of the deadline (pending Board approval) and was approved by Board in February Routine progress update reports were also submitted, as required, to Welsh Government in May and December Progress has been noted in a number of areas, along with challenges to delivery going forward, many of which are common to the local delivery of all the other Together for Health plans. For example, the PTHB HDDP has no lead officer or clinical lead for local delivery. This is the first HDDP Annual Report for PTHB. The intelligence presented in the report was produced and provided by Welsh Government or Public Health Wales for local use and commentary in the HDDP Annual Report; not all analyses are available at PTHB level. The analyses provided relate either to cardiovascular disease (CVD) or to coronary heart disease (CHD). Examples of particular features of note include that: Page 8 of 41

9 Further evidence has emerged that the age adjusted prevalence of coronary heart disease is significantly lower (better) in Powys than the rest of Wales Powys has the lowest (best) age-standardised emergency admission rate for CVD in Wales, significantly lower than the Wales average. As is the case nationally, age-standardised mortality rates from CVD have been falling in Powys since at least 2004; rates in Powys have tended to be statistically significantly lower (better) than Wales as a whole During the period 2011 to 2013, the premature mortality rate from CHD in Powys was the lowest (best) of all Health Boards and was statistically significantly lower (better) than the all-wales rate During the period 2009 to 2013, there was some variation in CVD premature mortality rates within Powys - but no area had a significantly higher (worse) rate than Wales and seven areas experienced rates which were significantly lower (better) than the Wales average Page 9 of 41

10 3. Overview of the Burden of Heart Disease Mortality Cardiovascular disease (CVD) - and within this, heart disease are amongst the most significant population health issues in Powys. For example, intelligence from the 2013 Welsh Health Survey 1 reported that 17% of adults in Powys are being treated for high blood pressure and 8% for any heart condition (excluding high blood pressure). The most significant cause of heart-related morbidity and mortality is coronary heart disease (CHD). Although mortality rates in Wales have been falling during the last three decades or so, rates in Wales remain higher than in England. In addition, mortality rates vary across Wales; for example, data for the period 2011 to 2013 (all age) indicates that the mortality rate from CHD has a strong relationship with socioeconomic circumstance. 2 Figure 1 shows age-standardised mortality rates for CHD in Wales for males and females aged under 75 years by deprivation fifths. For males, mortality rates are 2.4 times higher for those living in the most deprived fifth compared to those in the least deprived fifth. For females, there is a 4.4 fold difference in mortality rates. CHD outcomes are discussed further in the next section of the report. Figure 1 Mortality from coronary heart disease (ICD-10 I20-I25), European age-standardised rate (EASR) per 100,000, males and females aged under 75, Wales by deprivation fifth, Produced by Public Health Wales Observatory, using PHM, MYE (ONS) & WIMD (WG) Males Rate ratio Females Rate ratio % confidence interval Least deprived Next least deprived Middle Next most deprived Most deprived During 2011 to 2013, the premature mortality rate from CHD in Powys was the lowest (best) of all Health Boards and was statistically significantly lower (better) than the all-wales rate (Figure 2). 1 Welsh Health Survey 2013, Welsh Government Statistics released September Welsh Index of Multiple Deprivation 2014 and 2013, European standard population Page 10 of 41

11 Figure 2 Coronary heart disease mortality (ICD-10 I20-I25), European age-standardised rate per 100,000, persons aged under 75, Wales health boards, Produced by Public Health Wales Observatory, using PHM and MYE (ONS) 95% confidence interval Wales = 51 Betsi Cadwaladr UHB 46 Powys thb 37 Hywel Dda UHB 51 ABM UHB 60 Cardiff and Vale UHB 38 Cwm Taf UHB 65 Aneurin Bevan UHB European standard population. No adjustments have been made for the ICD-10 coding changes. Figure 3 summarises mortality rates from coronary heart disease (all age, male and female) in Powys (Middle Super Output Area analysis). Four areas in Powys had a significantly lower (better) mortality rate than the Wales average; no area had a significantly higher rate. Figure 3: CHD Mortality, Powys (all person, all age, , MSOA, EASR per 100,000 Page 11 of 41

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13 4. Outcome Indicators Through the national HDDP process, four outcome indicators were originally specified to track heart disease and service impact. These are: Outcome 1: prevalence rates of coronary heart disease and cardiovascular disease Outcome 2: emergency admissions for cardiovascular disease Outcome 3: mortality from cardiovascular disease Outcome 4: mortality rates within 30 days of a myocardial infarction Outcome 1: Prevalence Rates What would good look like? All patients with CHD would be appropriately identified and recorded on a practice register Intelligence on the prevalence of CVD and CHD is derived from local practice registers, established in line with the requirements of the national Quality and Outcomes Framework (QOF). (Figure 4) For example, the percentage of patients with coronary heart disease on registers increases with age, with males being more likely to be registered than females. Figure 4: QOF Prevalence of CVD and CHD: Wales and Powys 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% 2010/ / / /14 Powys CHD Wales CHD Powys CVD Wales CVD CVD and CHD prevalence appear higher in Powys than Wales and show a similar trend. However, no confidence intervals are available for these analyses, which need to be interpreted with a high degree of caution. Further, as the data is not agestandardised, it does not take into account the age structure of Powys and therefore does not reflect the higher proportion of older people in Powys, compared with Wales. In fact, findings from the Powys Heart Disease Needs Assessment demonstrated that the age adjusted prevalence of coronary heart disease was significantly lower (better) in Powys than the rest of Wales. Adjusting for age, the prevalence of coronary heart disease in Powys becomes significantly lower (better) than the rest of Wales (Figure 5). The apparent increase in cardiovascular disease prevalence (Figure 4) may reflect better detection and/or recording in primary care across Wales. Page 13 of 41

14 Figure 5 Patients on GP practice registers with coronary heart disease, agestandardised percentage, Wales health boards, Produced by Public Health Wales Observatory, using Audit+ (NWIS) 95% confidence interval Wales = 4 Betsi Cadwaladr UHB 3.9 Powys thb 3.3 Hywel Dda UHB Abertawe Bro Morgannwg UHB Cardiff & Vale UHB Cwm Taf UHB 4.3 Aneurin Bevan UHB 4.1 Further analysis has been undertaken at Powys cluster level, although confidence intervals are not available so differences should be interpreted with caution. (Figure 6) Figure 6: CHD Registration: GP Cluster Chronic Condition Analysis, 2013/14 Available at: Number of patients on CHD register % of GP cluster patients on CHD register Mid Powys 1, North Powys 2, South Powys 1, Health Board 5, Wales 110, The Table is limited to practices which had submitted data to Audit+ by 31/03/2014 Age-standardised % of GP cluster patients on CHD register In the 2013 Welsh Health Survey, 8% of the Powys population reported that they had a heart condition. However, the definitions used in these two studies and subsequent analyses are not comparable. Outcome 2: Emergency Admissions for Cardiovascular Disease Page 14 of 41

15 What would good look like? An established falling trend in CVD emergency admission rate Figure 7 summarises emergency admissions for CVD for Wales and Powys during 2012/13 and 2013/14. Figure 8 summarises age-standardised CVD emergency admission rates. Powys has the lowest emergency admission rate in Wales, significantly lower than the Wales average. The pattern of activity observed in Figure 8 closely mirrors the pattern of prevalence summarised in Figure 5. Figure 7: CVD Emergency Admissions: Wales and Powys, 2012/ /13 rev 2013/14 Powys Wales Source: PEDW February 2015 Figure 8 Page 15 of 41

16 Cardiovascular disease emergency hospital admissions, European agestandardised rate per 100,000, persons, all ages, Wales health boards, financial year 2013/14 Produced by Public Health Wales Observatory, using PEDW (NWIS) and MYE (ONS) 95% confidence interval Wales = 1,065 Betsi Cadwaladr UHB Powys THB Hywel Dda HB ABM UHB Cardiff & Vale UHB Cwm Taf HB Aneurin Bevan HB 1, ,444 1,151 Outcome 3: Mortality from Cardiovascular Disease What would good look like? An established falling trend in CVD mortality rates Age-standardised mortality rates from CVD have been falling over recent years (Figure 9). Rates in Powys have tended to be statistically significantly lower (better) than Wales as a whole. The improving trend is due in part to better prevention, better detection of CHD and CVD within primary care and better NHS treatment. Figure 9 Page 16 of 41

17 Cardiovascular disease mortality (ICD I00 - I99), European age-standardised rate per 100,000, persons aged under 75, Powys, Wales and England, Produced by Public Health Wales Observatory, using PHM and MYE (ONS) % confidence interval Wales England Powys thb EASR per 100,000 population Premature mortality rates are also lower (better) in Powys. Figure 10 shows that for the period 2011 to 2013, CVD premature mortality rates in Powys were significantly lower (better) than Wales as a whole. Figure 11 summarises CVD premature mortality across Powys (Middle Super Output Area analysis). As expected, there is some variation in rates within Powys, but no area has a rate significantly higher (worse) than Wales and seven areas have rates which are significantly lower (better) than the Wales average. Figure 10 Page 17 of 41

18 Circulatory disease mortality (ICD-10 I00-I99), European agestandardised rate per 100,000, persons, age under 75 years, Wales health boards, Produced by Public Health Wales Observatory, using PHM and MYE (ONS) 95% confidence interval Wales = 91 Betsi Cadwaladr UHB 87 Powys thb 72 Hywel Dda UHB 85 ABM UHB 105 Cardiff and Vale UHB 72 Cwm Taf UHB 110 Aneurin Bevan UHB European standard population. No adjustments have been made for the ICD-10 coding changes. Figure 11: Premature CVD Mortality: Powys Outcome 4: Mortality within 30 days of a Myocardial Infarction Page 18 of 41

19 What would good look like? An established falling trend in 30 day mortality following myocardial infarction The metric under consideration summarises premature mortality within 30 days of hospital admission following a myocardial infarction (heart attack). Across Wales, the rate fell (improved) between March 2010 and September 2014, from 4.31% to 3.35%. Figure 12: 30 Day Mortality following Myocardial Infarction: Wales (rolling 12 months; years) 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Mar 10 Jun 10 Sep 10 Dec 10 Mar 11 Jun 11 Sep 11 Dec 11 Mar 12 Jun 12 Sep 12 Dec 12 Mar 13 Jun 13 Sep 13 Dec 13 Mar 14 Jun 14 Sep 14 Wales Page 19 of 41

20 5. The Prevention and Management of Heart Disease The PTHB HDDP 2013/16 is summarised in Appendix 1, under the six national themes: 1. The promotion of healthy hearts 2. The timely detection of heart disease 3. Fast and effective care 4. Living with heart disease 5. Improving information 6. Targeting research The following sections of the Annual Report presents the position by theme, using the national assurance measures. THEME 1: The Promotion of Healthy Hearts Coronary heart disease can be prevented, including by addressing lifestyle factors such as smoking, alcohol consumption, lack of physical activity and obesity. In the context of the HDDP, the three measures of assurance for the promotion of healthy hearts are: Reducing the % of adults who are obese and reducing the % of adults who drink more than the recommended Government guidelines for alcohol consumption Reducing the number of people with diabetes Reducing the numbers of people diagnosed with hypertension and controlling diabetes amongst those diagnosed Overall, data from the 2013 Welsh Health Survey shows that 20% of Powys adults are obese (23% in Wales). The position for males and females in summarised in Figures 13 and 14 respectively; Figure 15 summarises age-standardised obesity rates for 2012/13. A range of actions are being taken in Powys to prevent and address obesity amongst children and young people and adults, through the Healthy Weight Action Plan. Page 20 of 41

21 Figure 13 Age-standardised percentage of adults reporting to be obese, males, Powys thb and Wales Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 25 95% confidence interval Powys thb Wales / / / / / Figure 14 Age-standardised percentage of adults reporting to be obese, females, Powys thb and Wales Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 30 95% confidence interval Powys thb Wales / / / / / Source: Welsh Health Survey (WHS), Welsh Government (WG), Page 21 of 41

22 Figure 15 Age-standardised percentage of adults reporting to be obese (BMI 30+), persons aged 16 and over, Wales health boards, Produced by Public Health Wales Observatory, using WHS (WG) 95% confidence interval Wales = 23 Betsi Cadwaladr UHB 21 Powys thb 20 Hywel Dda UHB 23 ABM UHB 23 Cardiff and Vale UHB 20 Cwm Taf UHB 26 Aneurin Bevan UHB 26 Figure 16 presents trend in the (age-standardised) proportion of adults consuming alcohol in excess of recommended guidelines (in this case, over 4 units per day in men and over 3 units in women, on the heaviest drinking day in the previous week). Figure 17 presents an age-standardised analysis; Figure 18 is an age-stratified analysis. The data on which these analyses are based are self-reported and are likely to be an underestimate of true alcohol consumption 3. As reported in the IMTP, a range of actions are being taken in Powys to prevent alcohol misuse. Figure 16: % Adults Consuming Alcohol in Excess of Guidelines 46% 44% 42% 40% 38% 36% Powys Wales Source: Welsh Health Survey 3 Alcohol and Health in Wales report, 2014 Page 22 of 41

23 Figure 17 Figure 18 Figure 19 summarises this drinking pattern across Wales (Upper Super Output Area analysis). Considering diabetes, analysis of GP registration data for the period 2008/9 to 2013/14 Figure 20 - shows an increase in diabetes amongst Powys adults, from 4.6% to 5.7%; this is consistent with the national trend. Figure 21 presents cluster-level analysis, although the data is not comparable to that used in Figure 20. The PTHB Diabetes Delivery Plan addresses the management of diabetes in Powys. Page 23 of 41

24 Figure 19. Figure 20: Prevelance of Adult Diabetes: Wales and Powys Page 24 of Powys Wales

25 Figure 21: Diabetes Registration: GP Cluster Chronic Condition Analysis, 2013/14 Available at: Number of patients on diabetes register % of GP cluster patients on diabetes register Mid Powys 1, North Powys 3, South Powys 1, Health Board 6, Wales 156, The Table is limited to practices which had submitted data to Audit+ by 31/03/2014 Age-standardised % of GP cluster patients on diabetes register Considering hypertension, 17% of Powys adults report being treated for hypertension, compared to 21% in across Wales (age-adjusted analysis). In terms of the control of hypertension, the proportion of hypertensive patients whose last blood pressure measurement was 150/90 or less increased (improved) over the period 2010/11 to 2013/14, from 77.5% in 2010/11 to 83.3% in 2013/14. (Figure 22) Figure 22: Patients with Hypertension whose last BP (measured in the previous 9 months) was 150/90 or less: Wales and Powys 86% 84% 82% 80% 78% 76% 74% Powys Wales Figure 23 summarises the overall age-standardised registration rate for hypertension. Figure 24 is a Powys cluster-level analysis of registration rates. Page 25 of 41

26 Figure 23 Proportion of patients with hypertension on GP practice registers, age-standardised percentage, persons, all ages, Wales health boards, 2012 Produced by Public Health Wales Observatory, using (QOF) Audit + (NWIS) 95% conf idence interval Wales = 11.1 Betsi Cadwaladr UHB 10.6 Powys thb 10.0 Hywel Dda HB 10.4 ABM UHB 10.9 Cardif f & Vale UHB 10.9 Cwm Taf UHB 12.9 Aneurin Bevan UHB 11.8 Figure 24: Hypertension Registration: GP Cluster Chronic Condition Analysis, 2013/14 Available at: Number of patients on hypertension register Page 26 of 41 % of GP cluster patients on hypertension register Mid Powys 4, North Powys 10, South Powys 5, Health Board 20, Wales 439, The Table is limited to practices which had submitted data to Audit+ by 31/03/2014 Age-standardised % of GP cluster patients on hypertension register

27 Although smoking does not feature in the HDDP assurance measures, it remains a highly significant, preventable risk factor for CVD. Smoking prevalence in Powys has decreased (improved) over recent years and currently stands at 19%, the best rate amongst Welsh Health Boards (Figure 25). Figure 25: Smoking Prevalence (age-standardised): Wales and Powys 30% 25% 20% 15% 10% 5% 0% Powys Wales Figure 26 compares age-standardised smoking prevalence between Health Boards (the data is not comparable to that used in Figure 25). Figure 27 summarises agestandardised smoking prevalence across Wales, based on the most recent Welsh Health Survey data (Upper Super Output Area analysis). Figure 26 Page 27 of 41

28 Proportion of adults who reported currently smoking, agestandardised percentage, persons, age 16+, Wales health boards, Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 95% confidence interval Wales = 23 Betsi Cadwaladr UHB 23 Powys thb 21 Hywel Dda HB 23 ABM UHB 23 Cardif f & Vale UHB 21 Cwm Taf UHB 26 Aneurin Bevan UHB 24 Figure 27: Smoking Prevalence: Wales Page 28 of 41

29 Progress on tobacco control has been focused through the Powys Tobacco Control Action Plan. Improving accessibility to, the promotion of and increasing referrals to smoking cessation services has been a priority. The focus has been on developing referral pathways from GPs, out-patients and partner organisations to SSW and level 3 pharmacy smoking cessation services. Care pathways have been developed for maternity and pre-operative smoking cessation services. Reference to smoking cessation services has been included in contract documentation for PTHB commissioned services. Locally, primary care providers and schools have been provided with promotional materials working with the British Heart Foundation, for example, to encourage local activity in support of No Smoking Day. The Stoptober campaign was also supported with the aim of encouraging individuals to make a quit attempt. There has been targeted work with maternity services and training has been delivered to PTHB health visitors on Smoke Free Homes; an action plan for roll out with other professionals is being developed. Exploratory work is under way to establish referral pathways through eye care services into local smoking cessation services. Making Every Contact Count (training frontline health professionals in behaviour change) will be rolled out across PTHB during 2015/16. Page 29 of 41

30 THEME 2: The Timely Detection of Heart Disease The three national assurance measures for the timely detection of heart disease relate to the clinical management of myocardial infarction; the clinical management of atrial fibrillation; and the provision of lifestyle advice for people with hypertension. Figures 28 and 29 summarise performance on aspects of the medical management of post-mi patients in primary care. Figure 28: Patients with a History of Myocardial Infarction on Specific Treatment (Evidence-based), Powys and Wales 2011/14 100% 98% 96% 94% 92% 90% 88% 86% 84% Powys Wales Figure 29: Patients with a History of Myocardial Infarction on Specific Treatment, Health Board Comparison (2013/14) Health Board Number of Patients on a CHD register Betsi Cadwaladr UHB 29, Powys THB 5, Hywel Dda HB 16, ABM UHB 21, Cardiff and Vale UHB 14, Cwm Taff UHB 12, Aneurin Bevan UHB 22, Wales 122, % of Patients with a History of MI on Treatment Atrial fibrillation is a common cardiac arrhythmia, affecting around 10% of the population aged over 75 years. Underlying causes include coronary heart disease and endocrine disorders; males are more likely to be affected than females. Around one in ten people with atrial fibrillation have no known underlying cause. Atrial fibrillation is a risk factor for stroke. Figures 30 and 31 summarise performance on aspects of the medical management of atrial fibrillation (anticoagulation or antiplatelet treatment). Page 30 of 41

31 Figure 30: Patients with Atrial Fibrillation on Specific Treatment (Evidencebased), Powys and Wales 2011/14 98% 97% 96% 95% 94% 93% 92% 91% Powys Wales Figure 31: Patients with Atrial Fibrillation on Specific Treatment, Health Board Comparison (2013/14) Health Board Number of Patients on an AF Register Betsi Cadwaladr UHB 14, Powys THB 2, Hywel Dda HB 9, ABM UHB 10, Cardiff and Vale UHB 7, Cwm Taff UHB 5, Aneurin Bevan UHB 10, Wales 60, % of Patients with Atrial Fibrillation on Treatment Figures 32 and 33 summarise primary care performance in relation to the provision of lifestyle advice (relating to physical activity, smoking cessation, alcohol consumption and diet) to patients with hypertension (high blood pressure) during the previous 15 months. Figure 32: Hypertensive Patients Receiving Lifestyle Advice, Powys and Wales 2010/14 85% 84% 83% 82% 2014/15 Annual Report 81% of the Page 31 of 41 Powys Heart Disease 80% Delivery Plan 79% 78% 77%

32 Figure 33: Hypertensive Patients Receiving Lifestyle Advice, Health Board Comparison (2013/14) Health Board Number of Patients on a Hypertension Register Betsi Cadwaladr UHB 115, Powys THB 22, Hywel Dda HB 63, ABM UHB 82, Cardiff and Vale UHB 63, Cwm Taff UHB 51, Aneurin Bevan UHB 93, Wales 493, % of Patients Receiving Lifestyle Advice THEME 3: Fast and Effective Care In Wales during 2014/15, patients with heart disease were managed within the 26 week referral to treatment (RTT) target (95% of patients to start their treatment within 26 weeks of GP referral). At the time of data provision for this report, the three assurance measures for the fast and effective care of heart disease related to this waiting time target and the management of acute MI ( call to balloon time - patients eligible for primary percutaneous coronary intervention - PCI - to be managed within the 150 minute response to delivery time). Performance is summarised in Figures 34 and 35. In Powys, access to fast and effective care is determined through PTHB s commissioning intentions and is subject to the HB s established contractual assurance arrangements at locality level - waiting times are reported through locality waiting list management meetings. Figure 34: Cardiac Referral to Treatment Time (RTT, all providers), Powys and Wales 100% 90% 80% 70% 60% Dec 12 Feb 13 Apr 13 Jun 13 Aug 13 Oct 13 Powys < 26w Powys <18w Dec 13 Feb 14 Apr 14 Page 32 of 41 Jun 14 Aug 14 Oct 14 Wales < 26w Wales < 18w Dec 14

33 Figure 35: Cardiothoracic Surgery, Referral to Treatment Time (RTT, all providers), Powys and Wales 30% 25% 20% 15% 10% 5% 0% Powys > 36w Powys > 53w Wales > 36w Wales > 53w During the period January to December 2014, average performance across Wales as a whole was that 89-91% of cardiac patients started their treatment within 26 weeks. A national drive to improve HDDP waiting times through the focused management of two component waits, within the overall waiting time, is now in place. With specific reference to cardiothoracic services, these are commissioned by WHSSC. As was reported to the Board of PTHB in June 2015, work to address the waiting times issue within these services was originally established by the Joint Committee of WHSSC during 2013/14 (the Cardiac Surgery: Improving Outcomes and Waiting Times Project ). This originally encompassed action to outsource some cardiac surgical services to England. During 2014/15, around 200 additional cardiac surgery interventions were funded by NHS Wales, to reduce waiting times. CVUHB first achieved the national waiting times target in October Across Wales, the number of patients waiting over 36 weeks for cardiac surgery had peaked at >200 patients in January 2014; by February 2015, the number waiting had fallen to <15. Further actions included agreement to establish a referral pathway from ABMUHB to CVUHB to manage demand during 2015/16, while capacity is being increased at Morriston Hospital. Considering the management of acute MI, the use of primary PCI has been improving in Wales - overall, 79.5% of eligible patients received the treatment during 2013/14, compared to 72% during 2012/13. During 2013/14, 75% of these patients received the Page 33 of 41

34 treatment within 150 minutes call to balloon time, an improvement of over 5% from 2012/13. Specific intelligence is not available for the Powys population. Figure 36 summarises the delivery of primary PCI within the target time of 150 minutes (call to balloon time) by hospital site. Figure 36: Primary PCI by Hospital: UHW, Morriston, Ysbyty Glan Clwyd 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% UHW MOR YGC Wales THEME 4: Living with Heart Disease The three assurance measures for Living with Heart Disease relate to the prevalence of MI, the (non-medical) treatment of MI and cardiac rehabilitation. Figure 37 summarises age-standardised revascularisation rates for MI in Wales for the period 2009/10 to 2011/12; the Figure should be interpreted with some caution, as the intelligence was not adjusted for prevalence (i.e. need ). Figure 37 Page 34 of 41

35 Revascularisation rates, European age-standardised rate per 100,000, persons, all ages, Wales health boards, 2009/ /12 Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS) 95% confidence interval Wales = 116 Betsi Cadwaladr UHB 105 Powys thb 87 Hywel Dda HB 116 ABM UHB 132 Cardif f & Vale UHB 120 Cwm Taf UHB 120 Aneurin Bevan UHB 121 Figure 38 summarises the uptake of cardiac rehabilitation across Wales following MI, PCI or CABG. Powys-specific intelligence is not available. In Powys, improved services to support patients with chronic heart disease are being developed, including cardiac rehabilitation - each PTHB locality is continuing to support nurse-led cardiac rehabilitation. For example, the south locality is undertaking work with a local practice to use risk stratification to inform development of a nurse-led clinic for patients with heart failure. Figure 38: Cardiac Rehabilitation following MI, PCI or CABG: Wales, 2010/14 80% 70% 60% 50% 40% 30% 20% 10% 0% MI PCI CABG Source: National Audit of Cardiac Rehabilitation, 2014 Page 35 of 41

36 THEME 5: Improving Information Theme 5 has no specific assurance measures. In relation to clinical audit, PTHB was ineligible to participate, as a provider of care, in most of the 2014/15 National Clinical Audit and Outcome Review Programme Cardiac Audits. However, the HB participated in the national Cardiac Rehabilitation Audit. Data from all eligible patients in Powys was entered onto the audit database on a continuous basis. THEME 6: Targeting Research There is one assurance measure for Theme 6, relating to the participation of patients with CVD in clinical trials (Figure 39). Overall, recruitment to cardiovascular trials between 2012/13 and 2013/14 increased, from 655 to patients. Although there were no relevant clinical trials in Powys, it is likely that Powys patients will have been recruited into trials being managed within other Health Boards (no specific figures are available). Figure 39: Participation of CVD Patients in Clinical Trials, 2010/ Looking Forward Looking forward, the overarching context for the future development and delivery of services for heart disease for the Powys population is the PTHB transformation programme, in particular, its Strategic Delivery Model and Commissioning Programmes. In addition, during 2015/16, action relating to the short-term priorities set by the All Wales Heart Disease Implementation Group should encompass: Development of a consistent model for the delivery of cardiovascular risk assessment, as part of the national approach Continuing to deliver the cardiac waiting time target through pathway development Development and implementation of the differential waiting time targets Development of new workforce models to release capacity Improving participation and case ascertainment in relevant national clinical audit activity / / / /14 Powys Wales Page 36 of 41

37 In addition, a Community Cardiology subgroup of the national Heart Disease Implementation Group has been established to lead the further development of community based services; PTHB has clinical representation on this subgroup. Page 37 of 41

38 APPENDIX 1 PTHB HDDP: Nationally Determined Priorities for the Period 2013/ /16 Theme 1: The Promotion of Healthy Hearts 1. Work with a broad range of partners (including Local Service Boards and the third sector) to: Raise awareness of healthy living Signpost existing sources of information, advice and support relating to lifestyle change Develop and deliver local strategies and services to tackle underlying determinants of health inequality and risk factors for coronary heart disease Target resources in population areas of high risk (such as areas of deprivation) and areas of high impact (including early intervention actions with children to tackle prevention from outset of life) 2. Support and facilitate GPs, practice nurses and community pharmacists to proactively: Ensure consistent provision of testing and treatment for risk factors such as high blood pressure and cholesterol Use every opportunity in primary care to promote healthy lifestyle choices and smoking cessation Theme 2: The Timely Detection of Heart Disease 1. Identify and implement ways of raising public awareness of the symptoms of heart disease and the importance of seeking urgent medical advice and raise awareness of when to ring 999, seek advice from NHS Direct and when to contact their GP 2. Provide GPs with timely access to diagnostic testing and procedures for heart disease, increasing direct access to testing (at the point of care or from a central laboratory), without need for secondary referral, where appropriate 3. Provide rapid access services to meet GP and patient need 4. Provide GPs with timely access to specialist cardiology advice through telephone and , speeding diagnosis for people who may not need referral to a clinic 5. Ensure adequate access to cardiac catheter laboratories, matched to population need 6. Raise symptom awareness of GPs and ensure through audit that people are referred to secondary and tertiary care in line with national guidance and referral protocols and pathways agreed by the cardiac networks 7. Provide specialist cardiology advice within 24 hours for those admitted to hospital with suspected heart disease - reorganising delivery of services to achieve this where necessary Page 38 of 41

39 8. Ensure effective collaboration between the All Wales Medical Genetics Service, Cardiac Networks, Hospital Lipid Clinics and GPs to use the Familial Hypercholesterolaemia Cascade Testing service to identify and treat individuals with Familial Hypercholesterolaemia and reduce the high risk of this group developing early onset heart disease 9. Ensure effective use of arrhythmia specialists and the All Wales Medical Genetics Service to ensure patients with inherited heart conditions have appropriate advice and testing and that specialist advice is provided to interpret the results Theme 3: Fast and Effective Care 1. Organise services to ensure people admitted because of diagnosis with a heart disease are assessed by a consultant cardiologist 4, within 24 hours of admission to hospital 2. Start definitive treatment in a timely manner, with a focus on driving down waiting times and meeting clinical need. As a minimum treatment must start in line with the 26 week Referral to Treatment waiting times target for cardiac disease 3. Deliver prompt and equitable access to appropriate interventions, including new diagnostic procedures, technologies, treatment and techniques, in line with the latest evidence and guidance and with evidence based policies and priorities agreed by NHS Wales 4. Ensure all complex surgery is undertaken with peri-operative care standards as in the ERAS project 5. Use the 1000 Lives Plus Programme to implement improvements to services for people with acute coronary syndrome, heart failure, atrial fibrillation and in need of anti-coagulation 6. Manage effective transition to quaternary services in England where needed 7. Coordinate effective discharge and timely repatriation of patients to local hospitals as soon as clinically appropriate following treatment in line with discharge plans and the All Wales Repatriation Policy 8. For patients who need it, ensure effective transition to appropriate palliative and end of life care, in line with the Delivering End of Life Care Plan 9. Develop an NHS Wales policy on Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions, ensuring that this always respects individual patient wishes 10. Review provision of defibrillators in public places and community first responders, within LHB areas, ensuring - in liaison with the WAST and the Page 39 of 41

40 British Heart Foundation - that there is adequate provision and training and an effective first responder in place Theme 4: Living with Heart Disease 1. Plan and deliver services to meet the on-going needs of people with heart disease as locally as possible to their home and in a manner designed to support self management and independent living. This should include as appropriate: Evidence based follow-up in the community where possible Drug and device management Cardiac rehabilitation (including psychological management and exercise) Exercise programmes (such as the National Exercise Referral Programme) Guidance on healthy lifestyle and self-care to minimise further ill health 2. Assess the clinical and relevant non-clinical needs of people with a diagnosis of a long term heart disease and in liaison with patients (and where appropriate family/carers) - record relevant clinical and non-clinical needs and wishes as the basis of implementing care in a care plan. This should include adults with congenital heart disease. The care plan should include information on what the diagnosis means for the patient, what to look out for and which service to access should problems occur; it should be reviewed at appropriate points along the pathway 3. Make arrangements to ensure that information in the care plan or GP letter is available both to the patient and recorded on clinical information systems - and is accessible to others who have clinical responsibility for the patient, including out-of-hours GP services, on a 24/7 basis 4. Provide access to expert patient and carer programmes when required 5. Work proactively with third sector services and provide effective signposting to information and support, enabling patients to easily access support services Theme 5: Improving Information 1. Ensure IT infrastructure supports effective sharing of clinical records/care plans 2. Put effective mechanisms in place for seeking and using patients views about their experience of heart services 3. Monitor and record performance against the Cardiac Disease National Service Framework and through annual self-assessment against the Quality Requirements and use the results to inform and improve service planning and delivery 4. Ensure full (100%) participation in mandatory national clinical audits, delivering significant improvements on current low participation rates - to support service improvement and support medical revalidation of clinicians and ensure that findings are acted on 5. Participate in and act on the outcome of peer review 6. Publish regular and easy to understand information about the effectiveness of heart services Theme 6: Targeting Research Page 40 of 41

41 1. Support and encourage protected research time for clinically active staff (in primary as well as secondary and tertiary care) 2. Build on and extend academic training schemes to develop a highly skilled workforce 3. Promote collaboration with key research initiatives such as CVRG-C and HBRU 4. Promote public health research, for example to identify the best ways of working with those who are most disadvantaged or to demonstrate how services meet individual and population needs 5. Invest in accurate collection of key clinical data in a format that can be incorporated into the SAIL (Secure Anonymised Information Linkage) database for populationlevel health and social care research including focus on epidemiology, impact of interventions on outcomes, clinical trail scoping and service delivery modelling and assessment 6. Collaborate effectively with universities and businesses in Wales to enable a speedier introduction of new evidence-based and cost-effective technology into the NHS Page 41 of 41