CWM TAF LOCAL HEALTH BOARD

TOGETHER FOR HEALTH - A HEART DISEASE DELIVERY PLAN

A DELIVERY PLAN UP TO 2016 FOR CWM TAF LHB AND ITS PARTNERS

DECEMBER 2013

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1. BACKGROUND AND CONTEXT “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 the following 6 themes:

• Promotion of healthy hearts • Timely detection of heart disease • Fast and effective care • Living with heart disease • Improving Information • Targeting research

This plan sets out how Cwm Taf Local Health Board (CTLHB), will address the key priorities set out by Welsh Government. The plan will also sit within the context of the Health Boards 1-3 year Integrated Plan, which sets out the Health Boards key deliverables over the next three years. The aim is to strengthen quality and assurance within a significantly challenging environment. Significant work is already underway within the Health Board to strengthen quality and assurance; to articulate actions that need to be taken to strengthen existing arrangements; to learn the lessons and consider the recommendations that have emerged from the Mid Staffordshire Inquiry and to continue a dialogue in public about “Cwm Taf Cares” the quality strategy for this organisation that is being co-created with our partners. The financial outlook and real terms reduction in resource allocation continues to present the most significant challenge of this type that the Health Board has faced to date. It is estimated that cash releasing efficiency savings of around £XXm will be required over the next 3 years to ensure financial balance in each year. This will provide a challenge for the Health Board in delivery the expectations of the Cardiac Delivery Plan over the next three years. The Health Board is however committed to driving up standards in Cardiac Services and is committed to reviewing services, systems and workforce across the whole cardiac pathway to facilitate service remodelling based on the needs of the population and the best

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available evidence of clinical and cost effectiveness. This in turn will allow the Health Board to achieve the best service model and patient pathways that will achieve optimum outcomes for patients within the available resource. This key principle and objective underpins the Cardiac Delivery Plan for Cwm Taf Local Health Board. In addition, the Health Board recognises the high level of morbidity and mortality from cardiovascular disease in the Cwm Taf area, as highlighted by the needs assessment. It is committed to addressing this significant challenge by a comprehensive prevention agenda, recognising that there will be a long lead time in seeing the planned outcomes from this work and that in the interim, we will also need to deal with increasing demands and challenges this places on services as the number of patients requiring treatment rise across the pathway from primary care to tertiary care. Many of the underlying determinants of heart disease are also the same for other disease groups such as stroke and diabetes and Cwm Taf plan to address many of these in a single work programme, the Inverse Care Law (ICL) programme that will underpin all three delivery plans. The initial focus of the ICL work will be cardiovascular disease, which will be further detailed in this plan. This plan will also need to be considered alongside the South Wales Programme (SWP), once the outcome of that work is known and in particular its implications on other acute service such as cardiology. __________________________________________________

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2. ORGANISATIONAL PROFILE Organisational Overview Cwm Taf Health Board was established on 1 October 2009 and provides a full range of hospital and community based services to the 289,400 residents of Merthyr Tydfil and Rhondda Cynon Taff. Almost 81% of the population live in Rhondda Cynon Taf Local Authority and the remaining 19% in the boundaries of Merthyr Tydfil. The Health Board’s catchment population increases to 330,000 when including patient flow from the Upper Rhymney Valley, South Powys, North Cardiff and the Western Vale. In July 2013 Cwm Taf Health Board was awarded University Health Board status by the Health Minister Mark Drakeford. This acknowledges Cwm Taf’s commitment to investing in staff, ongoing learning, research and development and our strong links with the communities we work in and serve. It recognises our commitment to excellence in the quality of services we provide and overall performance across the health board. It is the our belief that University Health Board status will help us in our ongoing drive to reverse the inverse care law and provide high quality response care and services for the communities with the greatest need.

Within Cwm Taf Health Board, Cardiac Services are currently delivered across the whole health board within Primary Care, Health Promotion, Secondary Care, diagnostic and Community services, with established links to specialist Tertiary care providers.

Cwm Taf Health Promotion Team supports the Health Board and its partners in delivering its health promotion and ill-health prevention services. Health promotion messages are reinforced across the whole pathway from primary care, secondary care and tertiary care.

Primary care provides a wide range of cardiovascular services including risk factor management.

Within secondary care the cardiac service is delivered across two DGH sites, Prince Charles Hospital (PCH) and Royal Glamorgan Hospital (RGH). There are 9 consultant posts across the two sites, 5 in RGH and 4 in PCH. The Cardiac Catheter Lab is located at RGH and delivers elective Angiography and Pacemaker implantation along with a limited number of more complex device procedures. Limited Pacemaker implantation also takes place at PCH. Secondary care Cardiology is managed within the Directorate of Medicine and Accident and Emergency. The Cardiologist takes part in the Medical

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on call rota on a 1: 20 at RGH and 1:15 at PCH. In addition to Consultant lead services, Cardiology consultant supervised services include Rapid Access Chest Pain Service, Nurse Led Arrhythmia and Heart Failure Services and a range of Cardiac Physiology Services being delivered by the Cardiac Physiology Team. Secondary care services are predominantly provided from Cwm Taf, but some patients receive their services from neighbouring Cardiff and Vale LHB, which is a remnant from a previous time period when there was a limited service provided from PCH. There are, however, some investigational cardiology services which Cwm Taf is still unable to provide and these services are provided for the residents of Cwm Taf from Cardiff and Vale LHB.

Tertiary Services, mainly interventional cardiology and cardiac surgery, are commissioned by Welsh Health Specialist Services Committee (SC) and provided mainly from the neighbouring Cardiff and Vale Health Board, with a very small number from the other main tertiary centre in South Wales at ABM Health Board. Highly complex cardiac surgery is provided from centres of excellence in England. WHSSC have developed a Heart Disease Delivery Plan and action plan for Tertiary Services and this is attached as Appendix E to this plan. Overview of Local Health Need and Heart Disease Challenge The Public Health Team have led and delivered a comprehensive Needs Assessment for Cwm Taf Health Board. A Copy of the Need Assessment is attached as Appendix A to this Plan. The key findings and messages from this work are as follows: • Deaths from cardiovascular disease (all ages) are higher than the

rest of Wales. • Death rates from cardiovascular disease are highest in the most

deprived populations. Thirty six percent of the resident population live in areas which are among the most deprived 20% (fifth) in Wales (WIMD 2011). Whilst the rates overall have decreased since 2001, the inequality gap has widened.

• Rates of premature mortality (under 75 years of age) from cardiovascular disease are the highest in Wales; death rates are highest in the most deprived areas and twice as high in males than females.

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• Premature mortality from coronary heart disease is the highest in Wales.

• The General Practice prevalence of hypertension and coronary heart disease (QoF 2012) is highest in Cwm Taf Health Board (12.9% and 2.9% respectively). This is statistically significantly higher than the Wales prevalence for hypertension and CHD (11.1% and 2.6%).

Lifestyle & Health Behaviours

• Smoking is a major risk factor for heart disease. In Cwm Taf

26% adults report being smokers. In households in Wales headed by someone who has never worked or is long term unemployed, this rises to 44% of adults. These household are concentrated in the most deprived areas.

• Over a quarter (26%) of adults reported being obese (WHS 2011/12); which was statistically significantly higher that the Wales average.

• A significantly lower proportion of adults who reported eating 5 portions of fruit or vegetables the previous day (27%). This was statistically significantly below Wales (33%).

• Regular physical activity can reduce the risk of coronary heart disease by 30%, but only 73% achieved the recommended levels of 30 minutes of physical activity on five or more days a week.

• Around 45% of adults reported drinking above recommended limits in the previous week (WHS 2011/12). One in three residents report binge drinking.

• The foundations for all aspects of human development (including heart health) are laid down in pregnancy and a person’s early years. Wales has the highest rate in the UK of women who smoke, consume alcohol and are who are obese during pregnancy. Cwm Taf are a Wales pilot site for more detailed models of data collection and analysis on this.

• The Child Measurement Programme for Wales indicates that the prevalence of overweight or obese reception year children (four and five year olds) in 2011/12 in Rhondda Cynon Taf was 31%, and in Merthyr Tydfil 34%. These rates compare to a Wales rate of 28%.

Access to Services

• Hospital admissions for all cardiovascular disease are higher than the Wales average. There has been an increasing trend in

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cardiovascular admissions for Merthyr Tydfil residents between 2009/10 and 2011/12.

• Emergency hospital admissions for both CHD and stroke are statistically significantly higher than the Wales average.

• The emergency admissions rate for CHD in males is more than double the same rate for women.

• Angiography rates (2009/2011) for RCT residents were statistically significantly higher than the Wales average whereas angiography rates in Merthyr Tydfil were statistically significantly below the Wales average.

• When revascularisation rates were correlated with under 75 year old death rates by LHB (as a measure of need), it suggests that Cwm Taf LHB has relatively low access rates given its mortality experience.

These findings present a significant challenge for the Health Board both in terms of addressing the increasing demand they put on services but more importantly how we improve the cardiovascular health of our population. These statistics that have influenced that cardiovascular disease be the first priority area of the ICL program and similarly being a priority area for the Health Boards 3 year integrated plan. ________________________________________________

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3. DEVELOPMENT OF CWM TAF HEALTH BOARD LOCAL DELIVERY PLAN Cwm Taf Health Boards Cardiac Delivery Plan, “Together for Health – A Heart Disease Delivery Plan” (2013), provides an opportunity to set out the Health Boards vision for cardiac services for its residents, on a whole system basis from prevention through to tertiary care, driving up service standards through service redesign. The Cardiac Delivery Plan has been developed in line with the Health Boards three main areas of focus in planning for and monitoring improvements over time: 1. Developing clear long term strategic objectives, which will frame

the development of short and medium term service improvement plans.

2. A clear (and rolling) set of priorities for improvement over the next three years

3. A clear understanding of the steps which are required in the short to medium term (1-3 years) to underpin the successful delivery of the Health Board’s longer term objectives and priorities.

In addition, the Cardiac delivery Plan will also follow the following five strategic objectives, derived principally from the Institute for Healthcare Improvements (IHI) Triple Aim, which provide a clear framework for the plan. These objectives are: To improve quality, safety and patient experience. To protect and improve population health. To ensure that the services provided are accessible and

sustainable into the future. To improve governance and assurance. To reduce the per capita cost of care in line with the resources

made available to the Health Board.

Within the Cwm Taf three year plan, the Health Board has set out a vision for Cardiac Services as follows:

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Our vision for heart care is for: - People of all ages to have as low as possible a risk of developing heart diseases and, where they do occur, an excellent chance of living a long and healthy life, wherever they live in Wales. - Wales to have incidence, mortality and survival rates for heart disease which are comparable with the best in Europe. We will use a range of indicators to measure success. These are being developed and will be refined over time and will include indicators such as: - Coronary disease prevalence rates: % patients under 75 living with coronary heart disease - Circulatory disease mortality rates under 75 per 100,000 population. - Survival following out of hospital cardiac arrest - Cardiovascular death in relation to average life expectance potential years of life lost. “ The plan has been clinically led by clinicians across primary and secondary care, with links to tertiary care from the planning process within WHSSC. This has allowed the plan to be developed ‘bottom up’ within the framework set by the Health Board. The Cardiac Delivery Plan will be owned at Directorate and locality level. This process has been overseen and led by the Cwm Taf strategic planning group. Whilst there have been key clinical leaders leading on aspects of the plans development, there has also been wider consultation with other clinicians involved across the cardiac pathway as well as within the wider Health Board. As the plan is implemented the Cardiac Planning Group will also review its progress and keep driving it delivery over the three year period. Similarly, Cwm Taf Health Board will seek assurance that the Cardiac Plan is being delivered in line with its three year and financial plans, requiring regular progress reports being presented to the Board via the Finance and Performance Committee, which oversees the Health Boards performance and delivery agenda. In addition, in line with the annual reporting framework to Welsh Government, there will be reports to the Board on progress. In line with good planning principles, It is recognised that the plan will not remain static over the three year period and will need to flex to reflect outcomes from reviews, clinical and performance standards as well as the outcome of the South Wales Programme and any changes in the financial framework for the Health Board over that period.

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4 . SUMMARY OF THE PLAN THE PRIORITIES FOR 2013 - 2016 The Cwm Taf Health Boards Cardiac Delivery Plan is underpinned by the needs of our population as identified in our local population cardiovascular needs assessment (Appendix A). The key emphasis is to drive up quality and access to services through service redesign, at the same time as driving on the prevention agenda for cardiovascular disease, but within the resources we have available to us, given the tight financial envelope the Health Board has to work with over the next three years. The main aim will be to use our resources clinically and cost effectively to ensure we get best value and optimise outcomes for patients within that resource. To that end, the plans are not aspirational, but whilst remaining challenging is also what we can realistically strive to deliver given this challenging financial climate. This therefore makes delivering the Cardiac Plan agenda a challenge for the organisation over the next three years. Delivery Theme 1 Promotion of healthy hearts and Timely detection of heart Disease The Welsh Government has set out the following priorities and delivery aspirations for 2013 – 2016:

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 change1 • 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:

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• Use every opportunity in primary care to promote healthy lifestyle choices and smoking cessation

• Ensure consistent provision of testing and treatment for risk factors such as high blood pressure and cholesterol

The Delivery Aspirations being: • High population awareness of the health harms of smoking and

alcohol consumption above recommended guidelines, the benefits of physical activity and healthy eating and of sources of help for lifestyle change

• Increased numbers of people who stop smoking • Increased numbers of people who lose a clinically significant

amount of weight (5-10% body weight), move in that direction. • Increased numbers of people undertaking sufficient physical

activity to benefit their health; • Reduction in alcohol consumption above recommended

guidelines • Effective identification and treatment of risk factors associated

with health inequality and heart disease.

The Single Integrated Plans for both Merthyr Tydfil and Rhondda Cynon Taf Local Authority areas represent a new approach to multiagency working in which health is a key partner. Many of the common priorities within both plans have the potential to have a key impact on cardiovascular disease, predominately tackling smoking and obesity, increasing physical activity and reducing levels of alcohol abuse. Below the overarching single plans sit a range of specific Cwm Taf strategies for managing Tobacco (Smoke free Cwm Taf Strategy and Action Plan), Obesity and Physical Activity (Healthy Weight, Healthy Valley Strategy) and alcohol (Area Planning Boards Substance Misuse Delivery Plans). In addition, tackling smoking and obesity have also been agreed as priorities for the Regional Collaboration Board across Cwm Taf. All these strategies aim to address health across the life course with particular recognition of the importance of working with children as early as possible to adopt healthy lifestyles through maternity, health visiting and school nursing services and programmes such as Cwm Taf Healthy Schools and Pre School Schemes. There is also great emphasis on helping to address inequalities by ensuring additional capacity is targeted into our areas of greatest deprivation. Through actively working in partnership with our Communities First programmes there is potential to target our more vulnerable communities. One of the key implementation routes for this priority area, amongst others, will be through the Inverse Care Law programme which is focused on reducing health inequalities in cardiovascular

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disease in Cwm Taf. The Cwm Taf Primary Care and Public Health Teams are working together to develop and implement a programme aimed at reducing the gap in life expectancy between the most and least deprived areas in Cwm Taf University Health Board. An overview of the Inverse care Law Programme for cardiovascular Disease is attached as Appendix B to this Plan for further information. An implementation plan is being developed for Cwm Taf (Draft Plan is attached as Appendix C), which is focussing initially on cardiovascular disease. The plan will detail specific interventions to be undertaken in primary care including an estimate of the numbers of individuals needing vascular risk assessment and the resource needed to deliver this as well as ensure optimal treatment of patients in practice. This plan has been developed alongside the Heart Disease, Stroke and Diabetes Plans and will inform the Health Board 3 year plan and the Primary Care and Community Strategy. The programme recognises the importance of a ‘whole of society approach’ to promote healthier, happier and healthier lives. Figure 1: A whole of society approach to promote healthier, happier and fairer lives

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In summary the programme has a number of priority commitments as follows: • To focus on premature mortality from cardiovascular disease

(approx 40 fewer deaths per annum in adults under 75 yrs across Cwm Taf).

• To be implemented across Cwm Taf Health Board targeting the Localities (six GP Cluster areas with the highest level of deprivation). The approach will be determined by the needs and maturity of the locality.

• To prioritise actions that should be able to demonstrate outcomes within 5 years.

• To focus on systematic and population scale implementation of evidence-based interventions.

• In the initial phase, the programme will focus on the determinants of inequalities in health that are within the control and influence of primary care and the wider locality networks.

There is an extensive programme of work and this programme also has its own action plan which is attached as Appendix C for further information and detail. The Action Plan for theme 1 – Promotion of Healthy Hearts is attached as Appendix D (i) Delivery Theme 2 Timely detection of heart disease The Welsh Government has set out the following priorities and delivery aspirations for 2013 – 2016:

• 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 G.P.

• 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

• Provide rapid access services to meet GP and patient need • Provide GPs with timely access to specialist cardiology advice

through telephone and email, speeding diagnosis for people who may not need referral to a clinic

• Ensure adequate access to cardiac catheter laboratories, matched to population need

• 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

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• 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

• 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

• 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.

The delivery aspirations being:

• High GP awareness of symptoms of heart Disease • Prompt and appropriate access to diagnostic testing and

specialist cardiology advice.

Cwm Taf will continue to work with the Cardiac Network and Public Health Wales to develop collaborative opportunities to take forward public awareness of the symptoms of Heart disease. The Health Board already promotes locally the importance of when to ring 999 or seek advice from NHS Direct etc as part of its emergency care plan. This information is well publicised across Cwm Taf. Key to delivering improvements to timely service is the need to redesign services and to deliver them in a different way. Our plans include introducing one stop clinics across both DGH sites, so providing timely access and diagnosis for patients as well as streamlining the patient journey and supporting the delivery of RTT targets. It is anticipated that the redesign of services and workforce will create more nurse led services such as rapid access chest pain clinics and arrhythmia nurse specialist services. Whilst redesign of the service and workforce is anticipated to facilitate some of the required expansion in nurse led clinics, additional resources may still be required which will provide a challenge in the projected 3 year financial framework and currently there is no additional resource identified for this plan. The plan outlines that both one stop nurse led clinics and rapid access to diagnostics will have resource implications for both the workforce and equipment. Until service redesign has been undertaken and any gaps in service identified, it is unclear of the size and cost of the gap in service. Given the financial position of the Health board over the next three years, it is anticipated that any expansion of services will be limited to that which can be achieved on a cost neutral basis.

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Work around planning for better utilisation of the catheter lab on the RGH site has already begun. Plans are to repatriate appropriate interventional cardiology work from the tertiary centre back to the local Catheter Lab at RGH. Cwm Taf is working with WHSSC who commission this activity to finalise these proposals. This will ensure that Cwm Taf consultants who currently operate in the tertiary centre can now work locally and allow patients to have their care closer to home and provide a more timely service. The plan is that this service will transfer with a resource to fund the service in RGH. As part of the service review and redesign work, it will be important that the patient pathway is supported by referral guidelines and protocols between component parts of the pathway to ensure patients move through it seamlessly and timely. This will include the guidelines both into and out of services to ensure that patients do not only get the right access into services but they also leave services at the right time and move to the appropriate part of the pathway to ensure we maintain the correct capacity along the pathway to meet RTT targets. The major challenge for the Health Board in terms of timely access is reducing waiting times for patients to see a consultant cardiologist. Cwm Taf Health Board does not meet the British Cardiac Society recommended consultant numbers for our resident population and going forward this gap will be a challenge as it tackles waiting times for Cardiology. In the current financial climate any plan to increase the number of cardiologist will be difficult. The plan is first is to maximise consultant capacity by freeing up resource through nurse led services. Until the impact of this is known, it is unclear what gap may remain. The current system of a joint rota between cardiology and medicine presents a challenge out of hours and at weekends if a cardiologist is not on call. The Health Board does not have any plans at present to change this arrangement and in particular will await the outcome of the South Wales Programme as to what the future configuration of cardiology services will be across South Wales. The Action Plan for theme 2 – Timely detection of heart disease is attached as Appendix D (ii) and Appendix E ( for Tertiary Care)

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Delivery Theme 3 Fast and effective care The Welsh Government has set out the following priorities and delivery aspirations for 2013 – 2016:

• Organise services to ensure people admitted because of diagnosis with a heart disease are assessed by a consultant cardiologist2, within 24 hours of admission to hospital

• 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

• 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

• Ensure all complex surgery is undertaken with peri-operative care standards as in the ERAS project

• 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

• Manage effective transition to quaternary services in England where needed

• 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

• 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

• Develop an NHS Wales policy on Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions, ensuring that this always respects individual patient wishes

• Review provision of defibrillators in public places and community first responders, within LHB areas, ensuring - in liaison with the WAST and the British Heart Foundation - that there is adequate provision and training and an effective first responder in place

The delivery aspirations being: • Prompt and appropriate access for all patients to clinically and cost

effective treatment and care in line with latest evidence and national standards and guidelines

• Assessment by a cardiologist within 24 hours of admission to hospital for all patients with a heart disease diagnosis

• For patients who need it, timely transfer to palliative and end of life services

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To deliver fast and effective services the Health Board recognise that services and workforce will need to redesign on a whole system pathway, to ensure patients move timely and seamlessly between primary, secondary and tertiary care to deliver the required improvements in services and quality. The emphasis will be to redesign services using the available evidence of what is clinically and cost effective to optimise outcomes for patients. Building on the work undertaken by WHSSC on prioritisation, Cwm Taf is looking to adopt this transformational approach to service redesign. Initial work has identified that we need to deliver services in a different way and use the workforce differently, especially developing more nurse led clinics.. Benchmark data has also identified we will need to develop strategies to reduce follow up rates. It will be key to ensure that we get the right patient to the right clinician/ service in the most timely and efficient way possible. The plan recognises the importance of enhancing GP skills in primary care to support timely discharge and facilitate more follow up work being undertaken in the community. There are still a lot of patients that are receiving their care in neighbouring LHB services. Further work is needed to understand why this happens and what opportunities there are to expand local to services to allow these patients to receive their cardiology services closer to home. There will be challenges with rising demand for services due to the poor cardiovascular health of the population, and resource restraints over the next three years will also be significantly challenging. During the implementation of the plan, it is expected that any implementation plan requiring additional resource will need a business case to be approved by the Board. The Action Plan for theme 3 – Fast and Effective Care is attached as Appendix D (iii) and Appendix E ( for Tertiary Care)

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Delivery Theme 4 Living with heart disease The Welsh Government has set out the following priorities and delivery aspirations for 2013 – 2016:

• 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 • 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

• Make arrangements to ensure that information in the care plan or fGP 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

• Provide access to expert patient and carer programmes when required

• Work proactively with third sector services and provide effective signposting to information and support, enabling patients to easily access support services

The delivery aspirations being: • People have timely access to information – tailored to their needs –

to ensure they understand their condition, what to look out for and what to do and which service to access should problems occur

• People’s clinical and relevant non-clinical needs and wishes are discussed with them (and if appropriate family/carers), recorded in a care plan, used to inform delivery of all care, and reviewed on an ongoing basis

• Care is given in the most appropriate place for the patient, as locally as is possible to the patient’s home

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• People have access to timely drug and device management, psychological management, exercise programmes and cardiac rehabilitation according to need

• Fewer people are admitted or readmitted to hospital unnecessarily or as an emergency

• People’s experience of NHS and third sector voluntary sector care and support services is integrated and seamless

• People are supported to manage their own condition Cwm Taf Health Board is committed to ensuring patients receive their care as close to home as possible, with a holistic approach to managing their cardiovascular disease. Key to that will be optimising their condition both with appropriate medicines management, appropriate rehabilitation and supporting people to manage their own condition. The Action Plan for theme 4 – Living with Heart Disease is attached as Appendix D (iv) and Appendix E ( for Tertiary Care)

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Delivery Theme 5 Improving Information The Welsh Government has set out the following priorities and delivery aspirations for 2013 – 2016:

• Ensure IT infrastructure supports effective sharing of clinical records/care plans

• Put effective mechanisms in place for seeking and using patients’ views about their experience of heart services

• 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

• 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

• Participate in and act on the outcome of peer review • Publish regular and easy to understand information about the

effectiveness of heart services The delivery aspirations being:

• IT and communication links which give clinical staff fast, safe and

secure access anywhere in Wales to the information needed to care for patients

• Patients and carers are regularly involved in the design of services; service users views on services are sought regularly and acted on to ensure continuous improvement

• Services are audited and reviewed systematically and findings are used to improve care.

• Transparently published information on NHS performance for heart disease is easily available

The Health Board is committed to improving the use of information and its use informing the planning for improvement cycle. . Historically it has experienced problems in having the capacity to enter data in all the audits. The redesign of the workforce will need to take into account the requirement to create capacity with appropriate staff to enter the data from audits to ensure we achieve the requirements of the plan. The Action Plan for theme 5 – Improving Information is attached as Appendix D(v) and Appendix E ( for Tertiary Care)

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Delivery Theme 6 Targeting Research The Welsh Government has set out the following priorities and delivery aspirations for 2013 – 2016:

• Support and encourage protected research time for clinically active staff (in primary as well as secondary and tertiary care)

• Build on and extend academic training schemes to develop a highly skilled workforce

• Promote collaboration with key research initiatives such as CVRG-C and HBRU

• 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

• Invest in accurate collection of key clinical data in a format that can be incorporated into the SAIL (Secure Anonymised Information Linkage) database for population-level health and social care research including focus on epidemiology, impact of interventions on outcomes, clinical trail scoping and service delivery modelling and assessment

• Collaborate effectively with universities and businesses in Wales to enable a speedier introduction of new evidence-based and cost-effective technology into the NHS

The delivery aspirations being:

• Flourishing heart research to improve prevention and treatment,

making NHS Wales an attractive place to live and work for high calibre clinicians.

• Rapid uptake of research findings. The Health Board is committed to encouraging and promoting research as part of its University Health Board status. The Action Plan for theme 6 – Targeting Research is attached as Appendix D (vi)

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5. PERFORMANCE MEASURES/MANAGEMENT The Welsh Government’s Heart Disease Delivery Plan (2013) contained an outline description of the national metrics that LHBs and other organisations will publish:

• Outcome indicators which will demonstrate success in delivering positive changes in outcome for the population of Wales.

• NHS assurance measures which will quantify an organisation’s progress with implementing key areas of the delivery plan.

A range of indicators will be used to measure our progress with the implementation of the plan. These indicators are being developed by the All Wales cardiac Implementation Group and are expected to be refined over time. These indicators will form the basis of the LHB’s annual report on heart disease that will be report both to the Health Board and Welsh Government and in line with Welsh Government requirement will also be made available to the public via the LHBs website.

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6. HOW WE PROPOSE TO IMPLEMENT The Health Board recognises the high level of morbidity and mortality from cardiovascular disease in the Cwm Taf area, as highlighted by the needs assessment and the corresponding demands this places on services across the whole pathway from primary to tertiary care. The challenge is to develop a twin approach to improving the cardiovascular health of the population and at the same address the growing demand for services, whilst driving up the standards of care. This all has to be achieved against a backdrop of a major service redesign across South Wales and a very challenging financial position. In addition, this cardiac Delivery Plan will need to fit into the Health Boards and Directorates three year Integrated plan as it evolves. Health Prevention will be a key driver over the next three years. Tackling some of the determinants of heart disease such as smoking, obesity and alcohol will be fundamental to our strategy, working with our partners, as well as promoting healthy lifestyles and increased activity for our residents. This will work will be taken forward as part of the Single Integrated Plans for both Merthyr Tydfil and Rhondda Cynon Taf Local Authority areas. Below the overarching single plans sit a range of specific Cwm Taf strategies for managing Tobacco (Smoke free Cwm Taf Strategy and Action Plan), Obesity and Physical Activity (Healthy Weight, Healthy Valley Strategy) and alcohol (Area Planning Boards Substance Misuse Delivery Plans). In addition, tackling smoking and obesity have also been agreed as priorities for the Regional Collaboration Board across Cwm Taf. Working with Primary Care Colleagues is also seen as pivotal to our implementation plans. One of the key implementation routes for this priority area, amongst others, will be through the Inverse Care Law programme which is focused on reducing health inequalities in cardiovascular disease in Cwm Taf. The Cwm Taf Primary Care and Public Health Teams are working together to develop and implement a programme aimed at reducing the gap in life expectancy between the most and least deprived areas in Cwm Taf University Health Board. In secondary care, key to implementation service redesign to ensure we use the available resources to best effective, so that services are both clinically and cost effective, achieving the optimum outcomes for patients within the available resource. We

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will also be reviewing the services that are provided for our residents by neighbouring Heath Boards, to explore opportunities to provide those services more locally for patients and change some of those patient flows back to services in Cwm Taf. Any changes in cross Health Board flows will be subject to partnership working with those Health Boards. Cwm Taf will also continue to support the implementation of the Cardiac Services Review for tertiary care services. The Health Board will be looking to benchmark services across the pathway to identify areas where efficiency can be improved. At the same time it will be looking to use clinical evidence and best practice to underpin service redesign, to ensure we develop the optimum service models and best clinical practice across the service. Alongside this the workforce will also be reviewed, using benchmark data, available evidence of best practice, to ensure we are optimising the workforce we have and also have the right numbers and mix of staff for the service models we require in the future. Once this review is complete, it is envisaged that there will be gaps in services and resources that will require a robust and evidenced based business case to be developed to secure service change and resources. It is anticipated that this will provide a challenge to the Health Board over the next three years with the scale of cash savings that need to be realised. These plans will be a key element of the Directorates three year plan for cardiology. It is also recognised that this planning process will need to be fluid to take into account the outcome of the South Wales Programme redesign work and its implications for cardiac services. Any change in the configuration of emergency care across South Wales will impact on acute cardiac care across the region. Therefore we have to recognise that as we plan to redesign services across Cwm Taf, we also might have to be planning to redesign services across South Wales as well.

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