ANEURIN BEVAN UNIVERSITY HEALTH BOARD TOGETHER FOR HEALTH - A HEART DISEASE DELIVERY PLAN

Transcription

1 ANEURIN BEVAN UNIVERSITY HEALTH BOARD TOGETHER FOR HEALTH - A HEART DISEASE DELIVERY PLAN LOCAL DELIVERY PLAN PROGRESS REPORT APRIL

2 Version Date Issued (03) v (03) v3 Brief Summary of Change Owner s Name Circulation Outcome 4: % 30 day hospital mortality rates for heart attack (rolling 12 months, ages 35-74) Aneurin Bevan University Health Board and Wales adjustment to explanatory text Celia Satherley & contributors Nigel Brown Linda Barrett for Executives Meeting WG Minor typographical errors Celia Satherley Associated Documents: Together for Health - A Heart Disease Delivery Plan - Local Delivery Plan (including appendices), Aneurin Bevan University Health Board (December 2014) Contributors Dr Nigel Brown Dr Alun Edwards Dr Jackie Austin William Beer Celia Satherley Clinical Director & Consultant Cardiologist NCN Cardiovascular Clinical Lead Consultant Nurse Heart Failure & Cardiac Rehabilitation Principal Health Promotion Specialist, Public Health Directorate Manager Cardiology & Neurology Abbreviations used in this document Acronym ABUHB CVUHB RGH NHH AF BP CHADS 2 CHD CVD LDP PCI QoF RTT Expansion/Definition Aneurin Bevan University Health Board Cardiff & Vale University Health Board Royal Gwent Hospital Nevill Hall Hospital Atrial Fibrillation Blood Pressure A clinical prediction rule for estimating the risk of stroke Coronary Heart Disease Cardiovascular Disease Local Delivery Plan Percutaneous Coronary Intervention (coronary angioplasty) Quality and Outcomes Framework (measures GP performance) Referral to Treatment 2

3 1.0 Introduction Together for Health a Heart Disease Delivery Plan was published by the Welsh Government in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government s expectations of the NHS in Wales to prevent avoidable heart disease and plan, secure and deliver high quality person-centred care for anyone affected by heart disease. It focuses on meeting population need, tackling variation in access to services and reducing inequalities in health outcomes across 6 themes. In response to the Together for Health A Heart Disease Delivery Plan (2013), the Health Board with its partners produced a Local Delivery Plan to demonstrate a systematic approach to progressive implementation of the Cardiac Disease National Service Framework for Wales, the Welsh Health Specialised Services Committee Review of Cardiac Services, and the All Wales Heart Disease Delivery Plan. The first iteration of this plan was produced by January The Health Board s Plan was updated in December 2014 to reflect elements of the All Wales Heart Disease Implementation Group s agreed short term priorities. This report to Welsh Government sets out the progress made locally in 2014/15 in addressing our heart disease delivery plan, the All Wales Delivery Plan, and progress against nationally agreed outcome indicators and assurance measures. 2.0 The Burden of Heart Disease There are good reasons for heart disease to be a key priority area for Aneurin Bevan University Health Board. According to the latest figures available from the Welsh Health Survey 1, 20% of adults are being treated for high blood pressure and 9% for any heart condition, excluding high blood pressure. The most significant cause of heart-related ill health and death is coronary heart disease (particularly angina and heart attack). Although death rates in Wales have been falling over the last 3 decades, they remain around 15% higher than in England 2. In addition, death rates vary significantly across Wales; the death rate in the most deprived fifth of wards is almost a third higher than in the least deprived fifth 3 - showing the pronounced impact of poverty and the socio-economic determinants of health. 3.0 How well are we doing in Aneurin Bevan University Health Board on heart disease? We are using four national outcome indicators to measure and track how well heart disease services are doing over time. These are: The prevalence rates of coronary heart disease and cardiovascular disease amongst our population. The numbers of emergency admissions for cardiovascular disease amongst our population. The number of people dying from cardiovascular disease in our region. The number of people who die in hospital within 30 days of having a heart attack. 1 Welsh Health Survey 2011, Welsh Government statistics released September Trends in Coronary Heart Disease , British Heart Foundation, The Cardiac Disease National Service Framework for Wales, Welsh Government,

4 Outcome 1: % QOF prevalence of Coronary Heart Disease (CHD) and Cardiovascular Disease (CVD) Aneurin Bevan University Health Board and Wales Prevalence rates for Coronary Heart Disease Prevalence rates: Cardiovascular Disease (Primary prevention) Wales CHD ABUHB CHD Wales CVD ABUHB CVD 2010/11 4.0% 4.1% 2010/11 1.2% 1.1% 2011/12 4.0% 4.1% 2011/12 1.6% 1.7% 2012/13 3.9% 4.0% 2012/13 2.2% 2.2% 2013/14 3.9% 3.9% 2013/14 2.7% 2.8% What does this mean? Prevalence is the proportion of a population found to have a condition. CHD and CVD prevalence is calculated by dividing the number of patients who have a condition associated with CHD and CVD by the total number of patients registered at GP practices. It is important to understand that this is not a true measure of prevalence within the population. The above data suggests that prevalence of CHD in our area is similar to the Welsh average and is declining, whereas the prevalence of CVD is increasing in line with Wales. There is a strong correlation between socio economic profile and the burden of disease. In areas of deprivation such as Blaenau Gwent, Caerphilly North and Newport West, the prevalence is lower than would be expected and the Health Board is investing in the Living Well Living Longer programme to identify at risk patients so that they offered healthy lifestyle advice and evidence based treatments to control risk factors. It is anticipated that this programme will increase the QoF prevalence of CHD in ABUHB over the next 5 years. 4

5 Outcome 2: Number of emergency admissions for cardiovascular disease amongst our population Numbers of emergency admissions for cardiovascular disease (CVD) (I00-I99) - ABUHB & Wales 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5, /13 rev 2013/14 Wales AB What does this mean? This tells us how many people are admitted to emergency departments related to *cardiovascular conditions. If we are successful, we would expect to see a continued fall in the number of admissions over time. The number of emergency CVD admissions at ABUHB in 2013/14 was 1.8% higher than in 2012/13 (6555 v 6436). In Wales as a whole, the increase in admissions for this patient group was 2.6%. * admissions include rheumatic heart disease, hypertensive diseases, ischaemic heart diseases, pulmonary heart disease, diseases of pulmonary circulation, any other heart disease, cerebrovascular diseases, diseases of the arteries, arterioles and capillaries, diseases of the veins and lymphatic system and any other unspecified disorders of the circulatory system 5

6 Outcome 3: Cardiovascular Disease (CVD) mortality rates (< 75 age standardised rate per 100,000) Aneurin Bevan University Health Board and Wales Cardiovascular Disease (CVD) mortality rates (<75, age standardised rate per 100,000) - ABUHB & Wales AB Wales. What does this mean? This outcome measure tells us how many people aged under 75 are dying from cardiovascular disease in our region. If we are successful, we would expect to see a continued fall in the mortality rate over time. The premature CVD standardised mortality rate per 100,000 in ABUHB is higher than the Wales average although the rate decreased from 2012 to There is a significant variation in the rate of premature mortality across ABUHB. The Public Health Wales Observatory has shown the association between deprivation and premature mortality from cardiovascular disease, which was presented in the Needs Assessment for the ABUHB Heart Disease Delivery Plan. The PHW Observatory has also produced maps and charts showing the pattern of premature mortality at small area (Middle Super Output Area) level which shows highest rates of premature mortality in North Caerphilly, Blaenau Gwent and areas of inner city Newport. 6

7 Outcome 4: % 30 day hospital mortality rates for heart attack (rolling 12 months, ages 35-74) Aneurin Bevan University Health Board and Wales. % 30 day hospital mortality rates for heart attack (rolling 12 months, ages 35-74) - ABUHB & Wales 7% 6% 5% 4% 3% 2% 1% 0% Aneurin Bevan Wales What does this mean? This outcome measure tells us how many people aged between 35 and 75 die within 30 days of being admitted to a hospital with a heart attack. If we are successful, we would expect to see a continued fall in the number of deaths over time. The above graph shows that hospital mortality rates within ABUHB for heart attack fell in line with the rest of Wales until early There has since been a small increase but at a time of development of a regional primary angioplasty service (PPCI). It is recognised that this is difficult data to compare across hospitals following such change in service because of differences in case-mix and characteristics of patients who are admitted to heart attack centres and Local General Hospitals. Data from the MINAP report 2015 (all ages) showed ABUHB hospitals to have a similar or lower mortality for STEMI patients admitted between 2011 and 2014 compared to the UK national average for non-primary PCI capable centres. 7

8 4.0 Our approach to tackling heart disease Significant changes in our outcome indicators will take time to effect. We are using nationally agreed NHS assurance measures to help us understand how well we are preventing, detecting and treating heart disease in ABUHB. In January 2014, we published our first Heart Disease Delivery Plan. We reviewed and refreshed this plan in December 2014 to ensure that our strategy and action plans reflect short term priorities agreed by the All Wales Heart Disease Implementation Group in November These were: - Developing a consistent model for the delivery of cardiovascular risk assessment - Delivering the cardiac waiting time target through more effective pathways - Developing and piloting component or differential waiting time targets - Reviewing workforce capacity and considering new models of delivery to release Capacity -Improving participation and case ascertainment in National Clinical Audit. Our Heart Disease Delivery Plan is designed to enable us to deliver on our responsibility to meet the needs of people at risk of heart disease or affected by heart disease. Priorities for heart disease are: Promotion of healthy hearts People are aware of and supported in minimising their risk of premature heart disease through healthy lifestyle choices and medication where possible Timely detection of heart disease Risk is managed and heart disease is detected quickly when it does occur, allowing timely progress to treatment Fast and effective care People with heart disease receive fast, effective treatment and care so they have the best possible chance of living a long and healthy life Living with heart disease Whether in the community or in hospital, people are placed at the centre of heart care with their individual needs identified and met so they feel well supported and informed and able to manage the effects of heart disease Locally we want to raise the standard of care for patients with heart failure; improve clinical and quality of life outcomes (more specifically a reduction in 30 day readmission across ABUHB; promote health, achieve equity of access, deliver care closer to home and enhance capacity. This will be achieved via a number of clinically proven interventions: - Identification of in patients discharge planning - Optimisation of treatment medication/self-management/cardiac rehabilitation - Multidisciplinary team working case management/ admission avoidance - Supportive and palliative care preferred priorities Improving Information Information systems to support high quality care, and performance, clinical audit and review information to drive service improvement 8

9 Targeting research A commitment to research, delivering improved prevention and treatment options and outcomes This annual report sets out the progress we have made against each of the priorities and sets out a baseline for future years against which progress can be monitored. 5.0 Promotion of healthy hearts Premature coronary heart disease is a largely preventable condition, significantly influenced by poverty and socio-economic health determinants - as well as factors such as smoking, alcohol consumption above recommended guidelines, obesity and lack of physical exercise. Achieving a reduction in levels of heart disease will require proactive approaches to tackling the underlying socio-economic determinants of health and promoting healthy lifestyles from childhood onwards. We have three assurance measures in this area. They are: Reducing the % adults who are obese and reducing the % adults who drink more than the recommended Government guidelines of units of alcohol per week. Reducing the number of people with diabetes in our region. Reducing the numbers diagnosed with hypertension and controlling it amongst those diagnosed. Progress against these assurance measures is highlighted below: % adults who are obese (age standardised) - ABUHB & Wales 27% 25% 23% 21% 19% 17% 15% AB Wales 9

10 What does this mean? Obesity is a preventable risk for heart disease. The chart above shows that the percentage of adults who are obese is increasing in both ABUHB and Wales. Furthermore the percentage of adults in ABUHB who are obese is consistently higher that the Wales average. Further analysis of this data from the Welsh Health Survey shows that since 2004/05, when compared to Wales, the percentage of adults with a BMI >30 has been significantly higher in ABUHB for both males and females. Analysis by local authority area also shows that for 2011/12 the % adults who drank more than the recommended Government guidelines of units of alcohol per week (age standardised) - ABUHB & Wales 45% 44% 43% 42% 41% 40% AB Wales What does this mean? Alcohol misuse is associated with an elevated risk of heart disease. The percentage of adults drinking in excess of recommended Government guidelines on units of alcohol per week in our area is decreasing in line with Wales. However, in terms of patterns of excess drinking, there are differences by both gender and age. For example, around 58 per cent of males aged and and 47 per cent of females aged report drinking above guidelines on the heaviest drinking day in the past week. The highest rate of heavy drinking is in Blaenau Gwent with 18 per cent of adults reporting heavy drinking (males over 12 units and females over 9 units) on the heaviest drinking day of the previous week. 10

11 % of people 16+ with diabetes % AB Wales What does this mean? Diabetes substantially increases the risk of CHD. The percentage of people aged 16 year and over diagnosed with diabetes in Aneurin Bevan increased between 2013/13 and 2013/14. % of patients with hypertension whose last blood pressure (measured in the previous 9 months) was 150/90 or less (QOF BP5) - ABUHB & Wales 88% 86% 84% 82% 80% 78% 76% AB Wales What does this mean? Hypertension is a major risk factor for CVD. The above graph suggests that the percentage of ABUHB hypertension patients with blood pressures measuring 150/90 or less was improving up to 2013/14 and was marginally better than the rest of Wales. Figures for 2014/15 are unavailable at the point of compiling this annual report. 11

12 Progress against our Promotion of Health Hearts Action Plans: Making Every Contact Count ABUHB is firmly leading a national approach to delivering Making Every Contact Count (MECC) in the NHS through advanced local delivery. ABUHB Midwives, Health Visitors and Community Pharmacy have all undertaken a train-the-trainer course and have subsequently trained hundreds of front-line NHS staff in 2014/15. Ensuring effective behaviour change takes place routinely requires more than yearly training, it needs to be embedded in operational and organisational processes. The MECC Operational Group, consisting of ABUHB Sexual Health Service, Midwifery, HR, Gwent Drug and Alcohol Service, Stop Smoking Wales, Health Visitors, School Public Health Nursing, Hospital Pharmacy and Primary Care Nursing, have produced learning plans which show how they intend to embed MECC. Smoking Cessation Smoking is a major risk factor for heart disease. Smoking cessation was included as a Tier 1 target in the NHS Delivery Framework 2013/14. The target aims to ensure that at least 5% of smokers make a quit attempt via smoking cessation services, with at least a 40% validated quit rate at 4 weeks. Following the introduction of the Tier 1 target an assessment was undertaken in ABUHB to determine whether capacity from the main provider of smoking cessation services (Stop Smoking Wales) was sufficient in terms of their ability to cope with increased demand. This assessment concluded that there was a significant shortfall in capacity which would need to be met by providing smoking cessation services in Community Pharmacy and Hospital settings. In January 2014, the ABUHB Board approved a business case to expand the range of smoking cessation services available to patients. Over the last year there has been a substantial improvement in referral and uptake to Stop Smoking Wales. This has been partly due to NCNs making smoking cessation a priority in their Network Plans. In February 2015, ABUHB were the top performing Health Board in Wales in relation to the number of Stop Smoking Wales clients that became treated smokers. Between January and March 2015, there was a substantial improvement when compared to the same period last year. Additional Health Board investment in 2014/15 has led to an increase in the number of community pharmacies offering smoking cessation services. There are currently 18 pharmacies commissioned to provide a Local Enhanced (Level 3) Smoking Cessation Service. Since these services were extended in September 2014, there has been significant increase in the number of clients accessing treatment. The Health Board has also funded a Smoke Free Support Service at the Royal Gwent Hospital and Nevill Hall Hospital which has only recently been launched and therefore data is not yet available on treatment outcomes for inpatient smokers. The service has two Smoking Cessation Counsellors who are available for inpatients and staff with provision for outpatients that require rapid access to smoking cessation support. The service is currently being provided in the Respiratory Directorate and is being rolled out into Cardiology. Plans are also being developed to extend the service to the Stroke wards and Medical Assessment Unit. The hospital service will be fully integrated with Community Pharmacy enhanced services to ensure seamless support for patients following discharge from hospital. 12

13 A full report with a breakdown of smoking cessation activity and outcomes will be available in due course. Adult Weight Management Service ABUHB have funded an Adult Weight Management Service which is now fully operational. A full report with a breakdown of activity and outcomes will be available for 2014/15 within the next few weeks. Childhood Obesity ABUHB are in the final stages of drafting a partnership Childhood Obesity Strategy and Action Plan along with a family-based childhood weight management service (Level 2 and 3) business case. Both developments have now been agreed with a range of relevant operational partners across the public service sectors. Alcohol Misuse In 2012, the Health Board became a Responsible Authority under the Licensing Act As a Responsible Authority, the Health Board can make representations to influence a Licensing Authority s policy (Local Authorities act as the Licensing Authority). A Responsible Authority can also make representations against granting a licence or request a review of a licence for individual premises. The Health Board has delegated responsibility for its Responsible Authority functions to the Executive Director of Public Health. The Aneurin Bevan Gwent Public Health Team is working with the other Responsible Authorities in Gwent to develop the Health Board s role as an active Responsible Authority. A multiagency group has developed a data sharing process for the sharing and coordination of data, within the framework of an agreed Information Sharing Protocol. The data will be used to provide evidence to local authority Licensing Committees when considering licensing applications or licence reviews. Health Inequalities Reducing premature mortality from Heart Disease In 2014/15, the ABUHB Living Well Living Longer Programme (LWLL) was funded to begin addressing the legacy of the inverse care law. The key focus of the programme is on reducing premature mortality from cardiovascular disease in deprived areas, particularly targeting men and women between the ages of 40 and 64. In the initial phase, the programme will focus on systematic and population scale implementation of proven interventions through engagement with primary care and its wider networks. The intention is to deliver a population scale programme of health checks to identify people at risk of CVD. These health checks are being provided by Health Care Support Workers in community settings with supervision from Registered Nurses. Each eligible individual is offered a minute session, in accessible, local community venues. The health check involves simple questions about age, ethnicity, lifestyle and family history. It includes near patient testing of cholesterol as well as a blood pressure measurement and pulse check. Height, weight and waist measurements are also taken to assess the individual s risk of diabetes. Those at high risk of diabetes will have an additional non-venous blood test, to assess whether they are likely to have diabetes. 13

14 Supported by customised software, the individual is provided with information on their risk of developing cardiovascular disease over the next ten years and their current heart age. Individuals at high risk can receive further support from a Health Trainer for up to six months. Direct referrals are also made to Stop Smoking Wales, National Exercise Referral Scheme, Adult Weight Management, Gwent Drug and Alcohol Service and the Expert Patient Programme. Results from the health checks are coded and electronically transmitted directly into the GP clinical system. This enables practices to follow up patients for further clinical management in a timely and efficient way. Participating GP practices are provided with direct and indirect support, including direct payment through a Local Enhanced Service, and support from Cardiff University through Clinical Academic Fellows scheme. The Health Board has allocated funding to the programme and has also received Welsh Government funding through the Improving Primary and Community Care Central Fund. The Living Well Living Longer Programme was officially launched by the Deputy Minister for Health, Vaughan Gething, AM, on 12 January Since the Ministerial launch, clinics have started in Tredegar. Over the last three months the Health Board has been working with Tredegar Health Centre and Glan Yr Avon Surgery to validate existing disease registers and identify eligible patients. To date, a total of 654 patients have attended for their Health Check in the Tredegar area. 6.0 Timely detection of heart disease The Welsh Government expectations of effective care to identify those at risk of avoidable heart disease are set in the National Guidelines and they expect health boards to manage that risk effectively and ensure systems are in place to detect heart disease where it does occur. There are three national assurance measures in this area. They are: % patients with a history of Myocardial Infarctions (MI) currently treated with specific medications % people with Atrial Fibrillation treated % people with hypertension who are given lifestyle advice 14

15 % patients with a history of Myocardial Infarctions (MI) currently treated (QOF CHD006W/CHD14) with specific medications - ABUHB & Wales 100% 95% 90% 85% 80% AB Wales What does this mean? 99% of patients in ABUHB cf 98% of patients in Wales receive appropriate medications after myocardial infarction. % people with Atrial Fibrillation treated (with CHADS score as in QOF AF6 and AF7) treated, ABUHB & Wales 98% 97% 96% 95% 94% 93% 92% AB Wales What does this mean? The above graph show that the percentage of patients with Atrial Fibrillation treated to reduce their risk of stroke increased significantly between 2011/12 and 2013/14 mirroring improvements across Wales. 15

16 % people with hypertension who are given lifestyle advice (QOF PP2) - ABUHB & Wales 87% 86% 86% 85% 85% 84% 84% 83% 83% 82% AB Wales What does this mean? ABUHB appears to perform slightly less well on giving lifestyle advice to people with hypertension compared with the rest of Wales. Initiatives to improve the detection of heart disease at the primary/secondary care interface include: /Telephone Advice Line - to facilitate easier access to advice for GPs from a cardiologist; Education ongoing programme of education for primary care colleagues. 2015/16 the focus will be on Atrial Fibrillation and anticoagulation. In Peer Review of referrals a proportion of referrals, which may not require review by a cardiologist are discussed at Peer Review Referral Group meetings attended by a GP and consultant cardiologists. Where appropriate, the referrals are returned to the referring clinician with advice regarding further management NTproBNP a blood test that may be used to rule out a diagnosis of heart failure. The threshold values for this blood test were altered in 2015 as a result of local and national experience. This should improve the specificity for heart failure and ensure only those patients requiring echocardiography and/or clinical assessment are referred from primary care. 7.0 Fast and effective care Some patients with heart disease will need to attend hospital for some part of their treatment, although we hope that an increasing proportion may be treated entirely in primary and community care. Hospital services need to be co-ordinated with excellent communication and handovers across boundaries, both within the acute setting and with primary care. Services should be delivered promptly, as close to 16

17 home as feasible and with a focus on positive patient experience. Fast, effective treatment and care ensures that people with heart disease have the best possible chance of living a long and healthy life. The three national assurance measures in this area are: Ensure that 95% of patients are treated within 26 weeks of referral to treatment No patients should wait more than 36 weeks from referral to treatment Ensure that those patients eligible for primary PCI are treated within a maximum of 2 ½ hours from call to help the call to balloon time target of 150 minutes ABUHB performance against Referral to Treatment (RTT) target in 2014/15 weeks April May June July Aug Sept Oct Nov Dec Jan Feb Mar Open pathway patients >26 weeks % weeks >36 weeks Time measured from receipt of referral from the GP to definitive treatment What does this mean? Health Boards are required to ensure at least 95% of patients will wait no more than 26 weeks from GP referral to treatment, including waiting times for any diagnostic tests and therapies required. The small number of patients not treated within 26 weeks (max 5%) must be treated with 36 weeks. The table above demonstrates that compliance with WG s 26 week Referral to Treatment target improved over the course of 2014/15. At the end of March 2015, 93.2% of cardiology patients commenced their definitive treatment within 26 weeks of referral by the GP (compared with 95% target) and no patients exceeded 36 weeks. Despite past investment and service modernisation, high demand for cardiology services at ABUHB has meant that it has been difficult to achieve Referral to Treatment targets in recent years. In recognition of the pressures, the Health Board invested in additional capacity solutions in the Cardiology hospital services from summer Specific target areas included reducing waiting times for initial outpatient consultation and the core diagnostic investigation of echocardiography. Recruitment difficulties and clinician absence hampered progress in significantly reducing waiting times for consultation. However, strategies to improve waiting times for echocardiography reduced waiting times from around 5 months to around 8 17

18 weeks for routine patients. Sustaining the improvements made over the course of 2014/15 represents a considerable challenge for the service. ABUHB waits for New Transthoracic Echocardiogram Census Patients waiting > 8 weeks ABUHB waits for New Outpatient (OP) consultation Census New OP > 26 weeks Total New OP waiting % Cardiothoracic Surgery Referral to Treatment (RTT) Welsh residents waiting >36wks & >53wks (at all providers) - ABUHB & Wales 35% 30% 25% 20% 15% 10% 5% 0% Dec-12 Feb-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Wales weeks AB weeks Wales- 53+ weeks AB weeks 18

19 What does this mean? The Welsh Government Referral to Treatment target that at least 95% of patients will wait no more than 26 weeks, and no patient shall wait longer than 36 weeks, applies equally to cardiac surgery. Most cardiac surgery for ABUHB patients is undertaken at the University Hospital of Wales, Cardiff. The graph overleaf shows that the percentage of ABUHB residents waiting in excess of 36 weeks for cardiac surgery reduced from 31.1% in January 2014 to 0% from October Similarly the percentage of ABUHB residents waiting in excess of 53 weeks for cardiac surgery fell from 8.3 % in January 2014 to 0% from October 2014 onwards. These improvements reflect a series of actions to reduce waiting times for cardiac surgery, including the outsourcing of selected patients to English hospitals between January and August Capacity solutions developed by Cardiff & Vale University Health Board in conjunction with Welsh Health Specialised Services Committee in 2014/15 are designed to sustain reduced waiting time going forward. In the interests of safety, the management of patients awaiting cardiac surgery has improved locally. Two cardiac rehabilitation clinical nurse specialists now ring all patients on a pre-planned basis using a symptom enquiry pro forma to escalate deteriorating patients, expedite admission, arrange timely investigations and initiate psychological support. Eligible patients that receive primary PCI within 150 minutes of calling for help (call to balloon) inc those admitted directly or transferred to Heart Attack Centre University Hospital of Wales Morriston Glan Clwyd Wales % 74.7% 77.8% % 57.7% 53.8% 70.3% % 61.8% 75.0% What does this mean? ABUHB heart attack patients would usually be taken to the University Hospital of Wales, Cardiff for PCI where compliance with the 150 minute call to balloon time (patient call for professional help to PCI treatment) requirement is very good. There is strong evidence that treating heart attacks promptly reduces the risk of development of heart failure and last sudden death. 19

20 Other progress against our Fast & Effective Care action plan priorities e-referral From April 2014, all new cardiology referrals from primary care are now sent electronically to Consultant Cardiologists desktops. The e-referral system has been modified to allow re-direction to diagnostic tests or out patients assessment or both and has significantly improved the process of prioritisation of referrals, reducing delays and benefiting patient care. Cardiac Catheter Laboratory The Royal Gwent cardiac catheter laboratory commissioned in 2005 is nearing end of life. The laboratory supports diagnostic coronary angiography, PCI and permanent pacemaker implantation. Two new laboratories will be commissioned in 2019 at the Specialist & Critical Care Centre (SCCC). In the interim however, the Royal Gwent laboratory requires replacement to ensure service continuity. The haemodynamic and picture archiving systems, key elements of the laboratory, were procured at the end of 2014/15 and will be installed in 2015/16. The radiology imaging equipment was selected as part of an All Wales evaluation process and will be purchased and installed in 2015/16. The identification of a decant solution to maintain laboratory services throughout the equipment replacement programme has been hampered by the space constraints and structural complications at the Royal Gwent Hospital. However, a solution has been identified and detailed planning is underway. Cardiologist of the Week The cardiac team at the Royal Gwent Hospital introduced a Cardiologist of the Week service, 7 days a week in June This ensures a Specialist sees all cardiac emergency admissions within 24 hours. Patients with very serious problems will often be seen immediately on admission. Fewer consultants at Nevill Hall Hospital have prevented the replication of this important development at that site. This will be reviewed however following the appointment of a new, 4 th consultant cardiologist in Living with Heart Disease The majority of heart diseases are chronic conditions that people can live with for many years. Meeting their sometimes complex and ongoing physical, psychological and social needs and managing the side effects of treatment can have significant benefits for improving patient outcomes and quality of life. The three national assurance measures in this area are: % of people who had an MI % of people who had a PCI or CABG % of people who took part in Cardiac Rehab - Wales 20

21 % of people who had an MI, PCI or CABG who took part in Cardiac Rehab - Wales 80% 70% 60% 50% 40% 30% 20% 10% 0% MI PCI CABG The percentage of people who took part in Cardiac Rehabilitation MI 40.0% 40.0% 22.0% PCI 15.0% 15.0% 30.0% CABG 72.0% 68.0% 68.0% The percentage of people who had an MI who took part in CR The percentage of people who had a PCI who took part in CR The percentage of people who had a CABG who took part in CR Source: National Audit of Cardiac Rehabilitation, 2014 What does this mean? Everyone with established CHD should be offered appropriate evidence based cardiac rehabilitation plan and have the high quality multidisciplinary cardiac rehabilitation support needed to achieve this plan. The above graph relates to all health boards in Wales. ABUHB offers a cardiac rehabilitation service for patients who have had a heart attack, PCI treatment or bypass-grafting surgery. Cardiac rehabilitation is not available for patients with stable heart failure in Newport or Caerphilly. 21

22 ABUHB CR data: number of eligible patients (from those referred into each team) compared against those who received a full assessment and those who participated in cardiac rehabilitation Eligible Assessed Attended Caerphilly no HF Newport N Gwent Torfaen There are four MDT teams predominately made up of specialist nurses, physiotherapists and fitness instructors; dietetics and pharmacists have limited involvement; there is one occupational therapist based in the north and a psychotherapist who covers ABHB (total WTE = 22.6) giving a ratio of 97.5 patients per 1. 0 WTE (recommendations are 71.5 patients per 1.0 WTE; Sign 2002). The service across ABHB is understaffed by 7.8 WTE. During the ABHB CR service received 1686 referrals of these 83% 1331 (79%) were eligible to be assessed prior to commencing CR; 790 (60%) of patients completed either a centre/ community based or home programme. This is higher than the UK average uptake of 43%. The call in the latest annual statistical report of the National Audit of Cardiac Rehabilitation is for the average uptake across all in-scope conditions to above 60% this is a huge challenge for resource depleted teams and when patients are presenting with more complex needs in terms of co-morbidities. There is a higher completion rate with higher staff to patient ratios in NH and Torfaen. The proportion of patients who wait <10days (aspirational target) from referral to assessment is 95%; under 6 weeks 85%. 22

23 The importance of the management of patients with heart failure from diagnosis to optimising treatment strategies such as medication, self management, device therapy, cardiac rehabilitation and palliative care is acknowledged by ABUHB Heart failure (HF) is the only major cardiovascular condition that has become more prevalent in recent decades. Based on current models of care, admissions from HF are due to rise by 50% between 2010 and 2035 (NICE, 2010). The relatively elderly population within ABUHB exacerbates this national trend. There is a significant rise in the prevalence of heart failure patients above the age of 80 years. The British Heart Foundation (BHF) (2102) estimates prevalence effects 2% of the population; rising to 7% of those aged 75 to 84yrs. The average prevalence from ABUHB s Quality and Outcomes Framework (QOF) registers is 0.95% thus highlighting an unmet need of at least 6000 patients. The estimated annual cost of heart failure is 2% of the NHS budget (ABUHB = 21m), 70% attributed to in-patient care. About one third of all heart failure patients are admitted to hospital each year. A review of emergency admissions to Nevill Hall Hospital (NHH) and Royal Gwent Hospital (RGH) identified 623 patient episodes with a primary heart failure diagnosis - 77% of cardiology admissions (n=802) and 2% of all medical emergency admissions (Wales Health Observatory). An additional 100 patients are admitted to Ysbyty Ystrad Fawr (YYF). With a median bed stay of eight days the estimated costs to ABUHB (at 400 per day) is 2,281,600 per annum. We know 50% of heart failure patients admitted to RGH are on non-cardiology wards (National Heart Failure Audit ) where heart failure treatment may be suboptimal. The number of HF admissions and readmissions at RGH and NHH RGH readmissions NHH readmissions At NHH, where resource allows, in-patient review by a 0.3 WTE HF Nurse Specialist, 30 day heart failure readmissions have remained below 8.5% for the last 4 years (e.g. 258 admissions, 22 readmissions 2013 NWIS) With the addition of an externally funded Acute HF nurse (0.4 WTE) at RGH in 2013 for a six month period, the rate dropped to below 8.0% but increased once the service was withdrawn to 11% (355 admissions, 39 readmissions). The Wales national average is 12%. Patients have benefited from the successful introduction of a Parenteral Heart Failure Nurse in the Community (2013) which has saved 540 bed days in 12 months. These 23

24 results are indicative of how the service links closely with Cardiologists, GPs and Palliative Care. When patients have the choice they prefer to die at home. The number of days of treatment vs. the number of referrals to the Parenteral Diuretic Service I really didn t want the treatment as it didn t work before in hospital, but I m glad the family and the doctor persuaded me to give it a try. I feel much better. I do not feel that I could have been offered any better care in hospital than I have received here at home A recent study commissioned by NHS Improvement (2013) modelled the relationship between uptake of cardiac rehabilitation (CR) and unplanned cardiac readmission rates, both nationally and at commissioner level. The results suggest that, over and above the well documented positive effects of CR on morbidity and quality of life, increasing the uptake of gold standard to >65% has the potential to reduce cardiac related admissions and deliver significant financial savings. Despite service redesign to maximise efficiency from within the current resource, the obstacle to providing optimal care across ABUHB is service inequity. There is inadequate provision of heart failure nurses in the Newport and Caerphilly community and no cardiac rehabilitation for patients with heart failure in either locality. It is sadly acknowledged that within the current resource the service only operates 9-5 during weekdays and provides no Heart Failure Nurse Specialist cover arrangements; not an ideal situation when the disease trajectory of these patients is so unpredictable. 24

25 Progress against our Living with Heart Disease action plans includes: Cardiac Rehabilitation - Anxiety and depression There are now two cardiac rehabilitation nurses trained as Cognitive Behavioural Therapists a project evaluating the influence of this specific intervention over a 6 month period proved to be positive on a range of patient focused outcomes such as readmission rates and psychological measures. Further work is required for this to become a substantive intervention. - Palliative care The nurse consultant is working with the lead palliative care consultant to provide advanced communication workshops for the heart failure nurses - National Certification Scheme for Cardiac Rehabilitation Two teams have submitted data for the pilot study to report in July It is anticipated all teams will participate in the scheme to commence Sept Inequity in Cardiac Rehabilitation services A business case for additional staff was submitted April 2015 and currently receiving attention within the Health Board. Adult Congenital Heart Disease (ACHD) Specialist ACHD services for ABUHB are currently provided by Cardiff & Vale University Health Board (CVUHB). In 2014/15, the ABUHB Cardiology service worked with other Health Boards and WHSSC to develop plans in support of a new hub and spoke ACHD service model and associated operational policy. From June 2015, an all day ACHD clinic will operate at Ysbyty Ystrad Fawr, led by the newly appointed ACHD consultant at CVUHB and also a named ABUHB cardiologist. The clinics will be populated with a mixture of ACHD patients repatriated from Cardiff and new ACHD referrals. This development will increase outpatient capacity for ACHD thereby reducing waiting times. 25

26 9.0 Targeting research Research is critical to effective heart care. Cardiovascular research in Wales is also vital in attracting investment and first class NHS staff. Cardiovascular research results in ongoing improvements in patient outcomes. Patients benefit through the on-going implementation of evidence based best practice. In the longer term, patients also benefit from better understanding of the causes and prevention of heart disease. There is one national assurance measure in this area: Number of Cardiovascular Disease (CVD) patients participating in clinical trials Number of cardiovascular patients participating in clinical trials - AB & Wales / / / /14 Aneurin Bevan All Wales What does this mean? Most cardiac research takes place in dedicated University Departments that are well resourced and funded and where staff have a primary research role or 50:50 split with NHS commitments. ABUHB Medical and Nursing staff are all full time NHS appointments. Nevertheless, they have contributed to 5 international clinical trials from heart failure though to secondary prevention, and future expansion in staffing may allow further interests and developments in these areas. 26

27 The HF & Cardiac Rehab nurse consultant is PI for a fully funded feasibility study entitled Spiritual Support in the Community for Patients with End-stage Heart Failure. Commenced in Sept 2014 patient recruitment is currently on track at 50%, the aim is 74 patients. Led by the HF & Cardiac Rehab nurse consultant, ABUHB in partnership with the Peninsula Medical School (Cornwall), York and Birmingham Universities is participating in a multi centre UK based study exploring the use of a self help manual to enable cardiac rehabilitation for patients with heart failure and their carers in the community. The research team was successful in obtaining full funding from the National Institute for Health Research RP PG The ReAblement in Chronic Heart Failure (REACH-HF). The HF & Cardiac Rehab nurse consultant was PI for the Feasibility NISCHR Portfolio supported study that commenced in April 2014 and the full RCT commenced Jan The site is on track with recruitment (aim 54 patients end Dec 2015) 10. Improving Information Participation in National Clinical Audits relating to heart care is a mandatory requirement which Local Health Boards must ensure is achieved. Full (100%) participation is required to effectively monitor progress in the delivery of heart care, to provide comparative outcome data and allow effective benchmarking. Over the past 12 months Aneurin Bevan University Health Board has participated in the following audits Clinical Audit Status Myocardial Ischaemia National Audit Project (MINAP) Acute Myocardial Infarction (heart attack)/acute coronary syndromes cases are reported to the MINAP audit. Data are collected at Royal Gwent Hospital and Nevill Hall Hospital only British Cardiac Interventional Society (BCIS) All PCI cases are reported to BCIS annually for the purposed of UK-wide national audit, which is subsequently reported in the public domain by BCIS. National Heart Failure Audit National Audit of Cardiac Rehabilitation Cardiac Rhythm Management Data are collected at Nevill Hall Hospital and Royal Gwent Hospital but we are unable currently to meet the 100% requirement due to poor audit data entry support. Much work has been done by the team to ensure central data reporting is accurate on an All-Wales basis. Data are entered by all teams. All PPM cases are reported to the National Institute for Clinical Outcomes Research for the purposes of UK-wide national audit. 27

28 ABUHB held one cardiology Mortality and Morbidity Meeting in 2014/15 for the purpose of driving up patient care. 11. Looking ahead in 2015/16 Considerable progress has been made against our action plan priorities and there have been a number of service improvements that have had a real impact on health care. The cardiac agenda for 2015/16 is significant, encompassing aspects of care in primary, secondary and tertiary care. Priorities for action over the coming 12 months include: Promotion of healthy hearts Sustaining the Living Well Living Longer initiative and growing a population scale programme of health checks to identify people at risk of CVD. Concluding a partnership Childhood Obesity Strategy and Action Plan along with a family-based childhood weight management service (Level 2 and 3) business case. Rolling out Smoke Free Support Service to further hospital inpatients, fully integrated with Community Pharmacy enhanced services to ensure seamless support for patients following discharge from hospital Timely detection of heart disease Exploring a GPwSI and Community Cardiologist model as a mechanism to deliver non complex cardiology consultation outside the traditional hospital setting to improve access and spread learning amongst GPs Fast and effective care Reviewing options to organise workforce so that staff only operate at the top of their clinical competence and the full MDT is utilised to greatest potential to release capacity. Refining workforce plans in preparation for the Specialist & Critical Care Centre opening from 2019 Working with other health boards, trusts and private providers to commission a phased increase in access to cardiac MRI over the next 5 years to improve diagnostic and prognostic information to optimise patient management and outcomes for a larger number of patients Exploring the development of a local Complex device therapy services (ICD) from 2016/17 in the interest of reducing inpatient waiting times for this treatment currently provided at UHW Replacing the end of life Royal Gwent cardiac catheter laboratory in 2015/16 Streamlining the management of urgent patients with serious clinical pathologies to ensure they are afforded priority booking and ultimately receive their definitive treatment at the earliest opportunity Applying the learning from the Cardiac Network workshops in 2015/16 to deliver the cardiac waiting times (16 weeks referral to diagnosis) through implementing more effective pathways 28

29 Developing plans to drive down waiting times for the full range of cardiac diagnostic tests and measuring progress against WGs pilot 8 week component waiting time reporting Progressing the publication of cardiac diagnostic test results e.g. echocardiogram results on the Health Board s Clinical Workstation to speed treatment planning Identifying plans to tackle follow up waiting times Introducing High Sensitivity Troponin I blood test to improve the detection of cardiac events in women in particular, and to facilitate earlier hospital discharge for those with negative results. Living with heart disease Addressing current shortfalls and geographical inequalities in HF nursing Commencing a new Heart Failure MDT meeting to support heart failure nurses in their management of complex and palliative patients by July 2015 Commencing a new, local Adult Congenital Heart Disease (ACHD) clinic from June 2015 Improving information Building on the All Wales HDDIG work programme to find ways to improve case ascertainment in national clinical audit. 29