Hywel Dda University Health Board Respiratory Health Annual Report November 2015

Hywel Dda University Health Board Respiratory Health Annual Report November 2015 Annual Report Respiratory CH v6 Page 1

CONTENTS PAGE Executive Summary 5 Introduction 6 Respiratory Incidence 10 Our Approach 14 Preventing Poor Respiratory 16 Detecting Respiratory Disease Early 19 Delivering fast effective care 21 Supporting People 26 Improving Information 27 Targeting Research 28 Conclusion 29 Annual Report Respiratory CH v6 Page 2

FIGURES Figure 1. All respiratory disease mortality rates in HDUHB and Wales per 100.000 population Figure 2. Number of all respiratory admissions and emergency admissions in HDUHB Figure 3. Number of admissions in HDUHB by respiratory condition Figure 4. Number of readmissions within 30 days of discharge in HDUHB by respiratory condition Figure 5. The percentage of patients in HDUHB and Wales registered with CIPD on a GP QOF register Figure 6. The percentage of patients aged 8 and over in HDUHB and Wales registered with asthma on a GP QOF register Figure 7. Percentage of adults in HDUHB and Wales who smoke daily or occasionally Figure 8. Percentage of patients in HDUHB and Wales aged 65+ and below 65 in the at risk groups who received influenza immunisation Figure 9. Percentage of smokers in HDUHB and Wales making a quit attempt and CO Figure 10. Prevalence of Asthma, COPD, in HDUHB and Wales and percentage of adults smoking in deprived areas Figure 11. Number of patients in HDUHB and Wales aged 15 or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months Figure 12. Percentage of patient sin Wales aged 65+ and ages below 65 in risk groups who received influenza immunisation Figure 13. Percentage of treated smokers who were CO validated as Quit 4 weeks PAGE 10 11 11 12 12 13 13 14 15 15 16 17 18 Figure 14. Prevalence of Asthma, COPD in Wales and 18 percentage of adults smoking daily and in deprived areas Figure 15. The high strength ICS prescribing (items per 19 100 PU s) for smokers Figure 16. Number of patients in HDUHB and Wales aged 20 15 or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months Figure 17. Number of patients in Wales with COPD in 20 whom the diagnosis has been confirmed by post bronchodilator Figure 18. GP referrals for patients with respiratory 21 conditions Figure 19. Average length of stay for admissions and 22 emergency admissions for all respiratory conditions Figure 20. Number of admissions by respiratory condition 22 Annual Report Respiratory CH v6 Page 3

Figure 21. Number of readmissions within 30 days of discharge for respiratory conditions Figure 22. Number of all respiratory admissions and emergency admissions Figure 23. Percentage of patients seen by a respiratory nurse/member of the COPD respiratory team Figure 24. Percentage of patients seen by a respiratory consultant or any other consultant physician Figure 25. Percentage of patients referred for pulmonary rehabilitation at time of discharge Figure 26. Percentage of low strength ICS prescribing for the national prescribing indicator Figure 27. Percentage of patients with Asthma, on a GP register, who have had an asthma review in the preceding 15 months Figure 28. Percentage of patients with COPD on a GP register who have had a review in the preceding 15 months Figure 29. Percentage of hospitals with on site palliative care services available for COPD patients Figure 30. Participation in a Health and Care Wales clinical trial 23 23 23 24 25 25 26 27 29 27 Annual Report Respiratory CH v6 Page 4

1.0 Executive Summary Overview of key achievements and progress over the past 12 months Hywel Dda UHB s Respiratory Delivery Plan (RPDG) was completed in September 2014. The first Hywel Dda Respiratory Planning and Delivery Group meeting took place on 24 th September 2014. There is a broad multidisciplinary involvement and representation. The Chair of the Health Boards RPDG is Dr Carol Llewellyn Jones Consultant Physician. The RPDG meets four times a year. Business cases have been completed for secondary care smoking cessation officers in Withybush and Bronglais Hospitals in line with current services at PPH and GGH to ensure equity of service across the Health Board. Funding has been secured to develop an early years smoking cessation service. This will support women in pregnancy to stop smoking as well as support and promote smoke free environments for families with pre-school children. Additional funding has been received to support the ongoing roll out of the Pharmacy Level 3 Smoking Cessation Service. Mind 1 Smoking Cessation Advisors have been working with the hospital smoking cessation service and West Wales Action on Mental Health to pilot a smoking cessation initiative using harm reduction principles in one acute psychiatric setting. Lifestyle Advisors project has been introduced into Primary Care as part of a systematic intervention to tackle the root causes of lifestyle choices. Clinical Flu champions identified Admission and discharge COPD bundles being tested in Bronglais Hospital. Discharge COPD bundle being tested in Glangwili and Withybush Hospitals BLF self-management packs now funded throughout the Health Board. 1 Mind is a mental health charity. Hywel Da Public Health Team have supported Mind to set up a smoking cessation service as part of the holistic support they provide to those will mental ill health. Annual Report Respiratory CH v6 Page 5

Implementation plan for Advanced Inhaler Technique Training and training commencing for trainers in December 2015. Asthma and COPD pathway for inhaler care implemented across the Health Board. Health Board working with BLF Wales to increase the number of Breathe Easy Support Groups across Hywel Dda. Improved links with the National Exercise Referral Scheme (NERS) in the Llanelli area and work continues to progress this across Hywel Dda. Working in partnership with the Llanelli GP Cluster and EPP to implement the community COPD+ programme TB Outreach Service with Community pharmacy finalist for Hywel Dda Best of Health Awards 2015 TB service business case written Ongoing work in COPD and Teleheath within the European United4Health Project with Dr Keir Lewis the Lead for COPD. Professor Keir Lewis has been appointed as Chair of Respiratory Medicine. 2.0 Introduction Background Hywel Dda has always been committed to improving the care for people who live with or at risk of a respiratory disease. A Respiratory Planning and Delivery Group was established in 2014 chaired by a Respiratory Consultant and supported buy all professionals working in respiratory care, patient representation, and BLF Wales representation. This broad multidisciplinary involvement includes GP S, secondary care consultants, secondary care and community care Respiratory Specialist Nurses, Occupational; Therapist, Physiotherapist, Operational management team, local public health team for smoking cessation and immunisations, medicines management, patient groups and patients. Progress Some excellent progress has been made and the support form the All Wales Respiratory Health Implementation Group has been beneficial. Preventing Respiratory Disease Preventing respiratory disease in our population is crucial and the best ways to achieve this is by working with Public Health Wales and partners. Members OF the local Public Health team are part of our health boards RPDG. Hywel Dda UHB with Public Health are working to gether to: Understand key population risks throughout the life course and then find when changes in behaviour occur (e.g. people stop taking physical activity or taking up smoking). Target resources to deliver interventions which prevent the change in behaviour in a timely manner, proportionate to need and inequality in health. Annual Report Respiratory CH v6 Page 6

Reduce smoking prevalence and inequality through: o Develop a clear understanding of the social and economic pressures in communities, e.g. deprived communities, and age groups where smoking rates are highest. o Support intensive targeted interventions to specifically address smoking cessation uptake with target groups. o Advocate increased action at population level including e.g. plain packaging, second-hand smoke exposure in children. o Ensuring that every contact with health services is used to both prevent smoking uptake and encourage cessation. Increase physical activity levels especially in older population groups. o Better understand why individuals stop exercising as they get older and how this can be prevented. o Support interventions with target age groups to increase participation in physical activity. o Better understand the motivations and barriers for undertaking physical activity. o Consider interventions within a settings approach. Business cases were completed for secondary care smoking cessation officers in Withybush and Bronglais Hospitals to ensure equity of service across the Health Board. Funding has been secured to develop an early years smoking cessation service. This will support pregnant women to stop smoking as well as support and promote smoke free environments for families with pre-school children. Additional funding has been received to support the ongoing roll out of the Pharmacy Level 3 Smoking Cessation Service. Mind 2 Smoking Cessation Advisors have been working with the hospital smoking cessation service and West Wales Action on Mental Health to pilot a smoking cessation initiative using harm reduction principles in one acute psychiatric setting. Lifestyle Advisors project has been introduced into Primary Care as part of a systematic intervention to tackle the root causes of lifestyle choices. Detecting Lung Disease Early The All Wales Respiratory Health Implementation Group (RHIG) has agreed funding across Wales for BLF Wales to run a Love Your Lungs campaign. Improvement s have been made to the stop smoking service in both primary and secondary care with newly appointed smoking cessation advisors in Bronglais and Withybush Hospitals and the level 3 smoking cessation service in community pharmacies. The appointment of Lifestyle advocates in primary care helps to sign post people with respiratory disease to the appropriate place as early as possible in their disease progression and supports people to identify the signs of needing to improve their lifestyle and sign posting on to relevant places 2 Mind is a mental health charity. Hywel Da Public Health Team have supported Mind to set up a smoking cessation service as part of the holistic support they provide to those will mental ill health. Annual Report Respiratory CH v6 Page 7

before the disease happens to help prevent people being diagnosed with a respiratory disease. Delivering Fast Effective Care TB Outreach Service with Community pharmacy finalist for Hywel Dda Best of Health Awards 2015. To ensure patient compliance with the TB treatment plan set out by the Respiratory Department by: o Providing a treatment option closer to the patients home o Dispensing in specified instalments - on specific days of the week o Ensuring each DOT dose is taken by the patient o Improving the patients understanding of their medicines o Liaising with the Respiratory Specialist nurse of any concerns or missed appointments o Monitoring for possible side-effects e.g. jaundice or visual disturbances, and notifying the Respiratory Team Hywel Dda UHB has produced and implemented new treatment pathways for COPD and asthma. This work was led by the medicines management team and supported across primary, community and secondary care. This is an excellent example of partnership working across all sectors of the services in Hywel Dda UHB. Ten health professionals are currently being trained in Advanced Inhaler Technique who will then provide a programme of training across the Health Board. Supporting People Living with Lung Disease Hywel Dda UHB has been working closely with BLF Wales to implement Integrated Breathe Easy Groups across all three counties. Llanelli Breathe Easy was launched in July 2015, Ceredigion Breathe Easy was launched in October 2015, Carmarthen and Haverfordwest Breathe Easy Groups were relaunched in November 2015. We have ensured close links between both our pulmonary rehabilitation service and our respiratory self management programmes with all the Breathe Easy Groups encouraging all participants to join one of the groups for continuing support. The self management programme team have been working closely with primary care to do increase awareness of the COPD Self Management for Life course that is available in the community and therefore increasing the number of courses available and the number of people with COPD completing a course A pilot project called COPD+ has been developed with Dr Williams GP Cluster Lead for Llanelli and the Self Management Team. This offers education and exercise for all those with are newly diagnosed or with mild COPD and don t fit the criteria for pulmonary rehabilitation. COPD+ is now being rolled out across other areas in the Health Board. Improving Information The All Wales RHIG has agreed funding for COPD and Asthma self management plans to be purchased for all health boards and used for all people with COPD and Asthma. Using BLF Wales self management packs for COPD and the Asthma UK self management packs for Asthma will ensure good practice and continuity of care. Annual Report Respiratory CH v6 Page 8

Target Research There are several ongoing research programmes across Hywel Dda related to respiratory care which includes both commercial trials and European. The European trial has been running for three years and has been looking at the use of telehealth following a hospital admission for an acute exacerbation of COPD. The findings are now being collated and will be available in 2016. In 201/15 196 patients were recruited into portfolio studies and there are 3 commercial trials in progress Trilogy, NTHi-004 and AFFIRM. Challenges Implementing change, identifying time and resource to implement change. Developing a robust respiratory service across Hywel Dda UHD whilst recruitment and retention of staff is difficult. Four Respiratory Consultant post currently vacant in Hywel Dda UHB. Large work loads of remaining staff means that there is limited time to attend national and local RPDG meetings. Withybush Hospital in particular has had no respiratory in patient service and limited outpatient service with has an effect on patient waiting times and performance. There is also a shortage of junior and middle doctors and review of whole respiratory MDT to support respiratory services is essential. Resourcing pulmonary rehabilitation across all three counties. Ceredigion still doesn t have a pulmonary rehabilitation programme. Need to review specialist nursing service in respiratory as there is a shortage in this team to support the TB service, ILD services, acute NIV services, domiciliary services and sleep services.. Lack of clinical lead for Respiratory services across the whole health board. Annual Report Respiratory CH v6 Page 9

3.0 Respiratory Incidence, Mortality and Emergency Admissions in Hywel Dda University Health Board Overview We are using four outcome indicators to measure and track how well our respiratory services are doing over time. These are: The mortality rate of people dying from respiratory conditions in our region. The incidence of COPD The incidence of asthma The reduction in the prevalence of adult smoking Outcome one: The mortality rate of people dying from respiratory conditions in our region This outcome measure tells us how many people are dying from respiratory conditions in Hywel Dda UHB. If we are achieving our objectives, we would expect to see a continued fall in the number of deaths over time. Currently there is no change in our mortality rates but compared to Wales our mortality rates are very low Figure 1. All respiratory diseases mortality rates in HDUHB and Wales per 100,000 population Annual Report Respiratory CH v6 Page 10

Figure 2. Number of all respiratory admissions and emergency admissions in HDUHB In Hywel Dda UHB our admissions and emergency admissions have remained fairly static over the past five years. Figure 3.Number of admissions in HDUHB by respiratory condition It is difficult to comment on the above information as the largest number of admissions sits under respiratory other and therefore we need to undertake a piece of work to establish what conditions sit is this group and if there is anything we can do to reduce this number. Annual Report Respiratory CH v6 Page 11

Figure 4. Number of re-admissions within 30 days of discharge in HDUHB by respiratory conditions Readmissions have gone down over the past five years and the health board will continue to work with primary, community and secondary care services to ensure this continues. Outcome two: The incidence of COPD This measure tells us how many people are registered with their GP with COPD. If we are successful, we would expect to see a continued fall in the number of registrations over time. However the health board is aware that if we continue our work to improve early and correct diagnosis we would expect the QOF register to increase initially. Figure 5. The percentage of patients in HDUHB and Wales registered with COPD on a GP QOF register The above shows that Hywel Dda UHB has slightly lower numbers registered on QOF than the Wales average. Annual Report Respiratory CH v6 Page 12

Outcome three: The incidence of asthma This measure tells us how many people are registered with their GP with asthma. Figure 6. The percentage of patients aged 8 and over in HDUHB and Wales registered with asthma on a GP QOF register The above shows that Hywel Dda UHB QOF registers for patients aged 8 and over are the same as the Wales average. Outcome four: The reduction in the prevalence of adult smoking This measure tells us how many adults report smoking daily or occasionally. If we are successful, we would expect to see a continued fall in the number of registrations over time. Figure 7. Percentage of adults in HDUHB and Wales who smoke daily or occasionally The above shows that the number of adult smokers across Hywel Dda UHB is continuing to reduce at a faster rate than across Wales Annual Report Respiratory CH v6 Page 13

. Twenty percent of the adult population of Hywel Dda report smoking. This continues the downward trend (Welsh Government, 2015). Carmarthenshire exhibits a higher smoking prevalence rate of 20% compared with rates of 19% in Ceredigion and Pembrokeshire. Smoking prevalence continues to be higher in the most deprived fifths of the University Health Board (UHB), however, services are being developed to ensure the needs of these groups are addressed through targeted provision of Stop Smoking Wales services, continued rollout of the Pharmacy Level 3 Smoking Cessation Service and support for smokers with chronic conditions and those waiting for elective surgery. Hywel Dda UHB is working towards the Tobacco Control Action Plan target of a reduction to a 16% smoking prevalence by 2020. 4.0 Our approach to respiratory health Significant changes in our outcome indicators will take place over time. We have developed a number of NHS assurance measures to help us understand how well we are preventing, detecting and treating, and supporting those living with respiratory conditions in Hywel Dda UHB. In Hywel Dda UHB, we published our Respiratory Health Delivery Plan in September 2014. The Plan is designed to enable us to deliver on our responsibility in delivering high quality care to patients with respiratory conditions. It sets out: Delivery aspirations we expect over the next year and ongoing Specific priorities Responsibility to develop and delivery actions Population outcome indicators and NHS performance measures Our priorities for respiratory health are: 4.1. Preventing poor respiratory health Figure 8. Percentage of patients in HDUHB and Wales aged 65+ and ages below 65 in risk groups who received influenza immunisation The Health Board is aware that we still are not ensuring a greater number of people with a respiratory condition are having an influenza vaccination. The local Flu Action Team produced a flu plan this year, with the hope of encouraging all service areas to Annual Report Respiratory CH v6 Page 14

take ownership of their targeted population and hence increase the uptake to ensure herd immunity. Figure 9. Percentage of smokers in HDUHB and Wales making a quit attempt and CO validated at 4 weeks Figure 10. Prevalence of Asthma, COPD in HDUHB and Wales and percentage of adults smoking daily and in deprived areas Cigarette smoke has been identified as a risk factor for the development, aggravation and/or progression of a number of respiratory diseases including COPD and asthma. Smoking is associated with more severe symptoms, an accelerated decline in lung function, increased hospital based care and increased mortality following hospital admission with an acute episode of near fatal exacerbation, compared to levels seen in non-smoking asthma patients ( Hylkema, 2007; Thomson, 2005). Annual Report Respiratory CH v6 Page 15

Asthma and COPD prevalence in Hywel Dda University Health Board (HDdUHB) is similar to the average for Wales with very little change in prevalence in the last 10 year period. Smoking prevalence has declined in HDdUHB however, smoking prevalence in some of the more economically deprived communities remains significantly high when compared to the Hywel Dda and Welsh average. Smoking cessation has been shown to improve lung function, reduce self- reported symptoms, medication use and improve asthma specific quality of life scores. In addition Smoking cessation has been associated with a decrease risk in COPD exacerbations with a 43% decreased risk of hospitalisation. While every effort should be made to prevent smoking uptake; smoking cessation programmes should be commissioned to ensure all smokers are offered appropriate and targeted opportunities to quit. 4.2. Detecting respiratory disease quickly Figure 11. Number of patients in HDUHB and Wales aged 15 or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months 5.0 Preventing poor respiratory health Health education and disease prevention strategies should inform everyday life style choices. We need to motivate people to be aware of, and take action to minimise their risk of premature respiratory disease through healthy lifestyle choices. In particular, reducing smoking will have the greatest impact. Appropriate vaccination programs (e.g. influenza) need to be further encouraged amongst target populations. Drug-induced lung disease should be identified quickly and information about causes disseminated widely amongst health professionals. This support and advice needs to be reciprocated by people taking personal responsibility for their lifestyle choices; having been made aware of the possible consequence those choices may have on the benefits of any future care that they may receive. Annual Report Respiratory CH v6 Page 16

From a tobacco control perspective the University Health Boards draft IMTP for 2015-16 outlines three key areas of investment to prevent poor respiratory health. This investment includes: Continued roll-out of Pharmacy Level 3 Smoking Cessation Services Expanding the existing in-hospital smoking cessation service to include Pembrokeshire and Ceredigion. Developing an early years smoking cessation service to improve health outcomes for mothers, babies and children. Additional activity includes: Development of the Lifestyle Advocates Project in Primary Care Promoting smoke free hospital sites Working with Local Authority partners to promote smoke-free school gates, playgrounds and beaches. Supporting the delivery of the Mind smoking cessation services Supporting smoking cessation in young people through the Iechyd Da Youth health team. We are using four assurance measures in this area. They are Uptake of the influenza immunisation programme Percentage of adults who attempt to stop smoking Prevalence of respiratory disease amongst adults in areas of deprivation High strength prescribing items for smokers Figure 12. Assurance measure one: Percentage of patients in Wales aged 65+ and ages below 65 in risk groups who received influenza immunisation This measure tells how many people aged over 65 and those in the at risk groups who have the vaccination for influenza each year, many of the over 65 s have reported anecdotally, that they are not attending their local surgery as this is the place for ill people to attend- therefore we will be looking at ways of working with the healthy population and promoting preventative work such as immunisation. Annual Report Respiratory CH v6 Page 17

Figure 13. Assurance measure two: Percentage of treated smokers who were CO validated as Quit 4 weeks This graph shows that the training to ensure all services adhere to NICE Guidance in relation to CO Validation is working and that quit rates identified by CO validation at 4 weeks has improved by 8% in 2014/15 compared to 2012/13 Figure 14. Assurance measure three: Prevalence of asthma, COPD in and percentage of adults smoking daily and in deprived areas This measure highlights the proportion of people who have asthma or COPD amongst those smoking on a daily basis and those living in deprived areas. This gives us a clear focus with regard to targeting our activities. Annual Report Respiratory CH v6 Page 18

Figure 15. Assurance measure four: The high strength ICS prescribing (items per 1000 PU's) for smokers This measure gives an indication of the proportion of smokers being treated with high strength prescriptions for a lung related condition 6.0 Detecting respiratory disease quickly The benefits of prompt diagnosis of lung disease are significant, particularly in such conditions as asthma, COPD, sleep-disordered breathing, occupational lung diseases and a wide range of interstitial lung diseases. There is a need for greater public awareness of the symptoms of such lung diseases, of the risks posed by smoking and by any delay in diagnosing smoking-related lung conditions such as lung cancer and COPD. We are using three assurance measures to track performance in this area. They are: Smokers who have had an offer of support and treatment within the last 27 months People diagnosed with COPD confirmed by post bronchodilator GP referrals Annual Report Respiratory CH v6 Page 19

Figure 16. Assurance measure five: Number of patients aged 15 or over in Wales who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months Figure 17. Assurance measure six: Number of patients in Wales with COPD in whom the diagnosis has been confirmed by post bronchodilator Annual Report Respiratory CH v6 Page 20

Figure 18. Assurance measure seven: GP referrals for patients with respiratory conditions Over time we would expect to see GP referrals increase as they become better at identifying individuals who may be suffering from a respiratory condition 7.0 Delivering fast, effective treatment and care Conditions affecting respiratory health are numerous, varied and often complex, requiring a multidisciplinary approach to management offered by many different providers. There are five lung conditions where improvements in the delivery of effective care can result in high impact changes to the people of Wales s respiratory health. These are: Asthma; Chronic Obstructive Pulmonary Disease (COPD) and Bronchiectasis; Interstitial Lung Disease; Sleep-Disordered Breathing; and Acute Respiratory Care. Asthma COPD and Bronchiectasis Interstitial Lung Disease Sleep disordered Breathing Acute Respiratory Care Annual Report Respiratory CH v6 Page 21

Assurance Measure 8: Admissions, readmissions and LOS for respiratory disease Figure 19. Average length of stay for admissions and emergency admissions for all respiratory conditions It is pleasing to note that the average length of stay has reduced across Hywel Dda UHB for a hospital admission but this does identify that we remain 0.5 of a day over the Wales average and will continue to work to improve this. Figure 20.Number of admissions by respiratory condition Annual Report Respiratory CH v6 Page 22

Figure 21. Number of re-admissions within 30 days of discharge by respiratory conditions Figure 22. Number of all respiratory admissions and emergency admissions Annual Report Respiratory CH v6 Page 23

Assurance measure 9:COPD Inpatient data Figure 23. Percentage of patients seen by a respiratory nurse/member of the COPD respiratory team Hywel Dda UHB ensures 42% of patients admitted to secondary care are seen by a member of the respiratory team. This is the same as the Wales average and lower than the England average work needs to continue to improve this. Figure 24. Percentage of patients seen by a respiratory consultant or any other consultant physician This graph shows that Hywel Dda UHB is below both the Wales and England average and further work needs to be done to improve this. Please see the challenges section of this report. Annual Report Respiratory CH v6 Page 24

Figure 25. Percentage of patients referred for pulmonary rehabilitation at time of discharge Hywel Dda UHB only has pulmonary rehabilitation in 2 of the 3 counties currently and has a wating list for the programme. Further work needs to be undetaken to improve access to pulmonary rehabilitationand then referrals should improve. Figure 26. Percentage of low strength ICS prescribing for the national prescribing indicator Hywel Dda UHB is slightly above the Wales average of 39% at 40%. The introduction of the new pathways for prescribing of inhalers for COPD and Asthma should improve this. Annual Report Respiratory CH v6 Page 25

8.0 Supporting people living with lung disease Education is key to improving awareness of respiratory disorders and associated symptoms, helping achieve an earlier diagnosis and improved self-management. Having confident and informed respiratory patients at the centre of the decisionmaking processes will allow them to take ownership of their conditions leading to fewer unplanned primary care consultations, reductions in visits to outpatient departments, reduced hospital admissions and reduced length of stays in hospital. Individuals with chronic lung disease benefit greatly from a multidisciplinary approach to care and gain the most benefit from this care if delivered in the community, closer to home. This ensures that individuals have two key elements of care: physical and psychological support. These are important, when living with such chronic disease, to help the individual cope with distressing symptoms such as breathlessness, as well as ensuring that respiratory infections are treated earlier to prevent worsening structural damage to the lungs. Professionals involved in supporting individuals with respiratory conditions should be trained in techniques which build self-sufficiency in their clients and address health related behaviours such as smoking and obesity. Pulmonary rehabilitation provides many aspects of this care and should be available locally for all patients with chronic lung disease, with further support accessible through the National Exercise Referral Scheme (NERS) Respiratory Disease Pathway, designed to increase the long-term adherence in physical activity of patients. Patients with advanced disease need prompt access to effective palliative end of life care. We are using three assurance measures to track our progress in this area. They are: The percentage of people with asthma who have a regular asthma review The percentage of people with COPD who have a regular review Hospital on-site palliative care services availability Figure 27. Assurance measure 11: Percentage of patients with asthma, on a GP register, who have had an asthma review in the preceding 15 months Annual Report Respiratory CH v6 Page 26

Figure 28. Assurance measure 12: Percentage of patients with COPD on a GP register who have had a review in the preceding 15 months Figure 29. Assurance measure 13: Percentage of hospitals with on-site palliative care services available for COPD patients 9.0 Improving Information Participation in national clinical audits is a requirement which health boards must ensure is achieved. Full (100%) participation is required to effectively monitor progress in the delivery of care for people with a respiratory condition, to provide comparative outcome data and allow effective benchmarking. The Health Board has undertaken national clinical audits as required as well as local audits. These include the following Annual Report Respiratory CH v6 Page 27

National Pulmonary Rehabilitation COPD (NCAORP) A snapshot audit of service delivery and quality. To enable providers of pulmonary rehabilitation for COPD to improve the quality of care provided in these settings, through the provision of high quality, time-limited data collections. Local BTS Community Acquired Pneumonia (CAP) - The aim of the BTS audit programme is to drive improvements in the quality of care and services provided for patients with respiratory conditions across the UK. Smoking cessation services in hospitals (To pilot National Audit tool on behalf of the British Thoracic Society, only site in Wales selected.) To establish scope and effectiveness of current smoking cessation services within 2 out of 4 hospitals; to aid business plan to develop smoking cessation services within WGH and BGH and to measure compliance with HB Tier 1 targets. NCAORP National Lung Cancer Audit 2015/16 - The National Lung Cancer Audit looks at the care delivered during referral, diagnosis, treatment and outcomes for people diagnosed with lung cancer and mesothelioma. BTS Asthma Paediatrics - Monitor affective treatment of viral wheeze and asthma patients admitted for more than 4 hours over 1 years of age. BTS Emergency oxygen audit in adults at Bronglais Hospital Management of acute Asthma admissions to A+E - To improve early recognition of the severity of asthma admissions, to improve initial investigation and treatment of acute asthma and to improve follow up after acute asthma admission to A+E. COPD Discharge Bundle To see if the implementation of the bundle has an impact on reducing admissions for COPD, increasing referral rates to Pulmonary Rehabilitation and the COPD self management for life programme, improve the use of correct inhaler theray, improve referrals to the smoking cessation service and improve follow up arrangements. Nicotine Replacement Therapy (NRT) prescribing for inpatient smokers in GGH & PPH - To quantify the proportion of patients that have their smoking status documented in the medical notes on admission, to determine the proportion of inpatient smokers offered NRT on admission, to determine whether NRT has been prescribed for inpatients smokers during their admission and on discharge, to assess whether NRT is appropriately prescribed in accordance with the produce licence and to determine whether the NRT prescribed for patients is readily available on the ward. 10.0 Targeting research Research is critical to effective care for people with a respiratory condition and the NHS must respond to the latest research evidence in the planning and delivery of its services. Respiratory research in Wales is also vital in attracting investment and first class NHS staff. Wales already has an excellent reputation in this area. Annual Report Respiratory CH v6 Page 28

We are using one assurance measure to track our progress in this area; it is the number of people who participate in a research trial. Figure 30. Assurance measure 14 Participation in a Health and Care Wales clinical trial Over time we would expect the numbers participating in a clinical trial to increase The recent appointment of the Chair in Respiratory Medicine with Swansea University will support and increase the current active research profile 12.0 Conclusion and focus for the next 12 months and beyond The Health Board feels that we have made good progress over the first year even with the challenges that are in place in particular the recruitment and retention of staff across all three countries. Our priorities for the next year are to continue to develop what we have achieved so far and the following: Appoint and retain staff, across the MDT as it remains difficult to implement the respiratory plan with 50% of consultant posts vacant and lack of supporting staff Smoking cessation services Spirometry ARTP accredited training level 3 Early Detection of lung disease by undertaking a Love your Lungs event with BLF Wales Annual Report Respiratory CH v6 Page 29