DRAFT LIVER DISEASE DELIVERY PLAN...Autoimmune liver disease – where the body’s immune system...

AGENDA ITEM 3.4 APPENDIX 4

DRAFT LIVER DISEASE DELIVERY PLAN

2015-2016

1. BACKGROUND AND CONTEXT “Together for Health – Liver Disease Delivery Plan” was published by the Welsh Government in 2015 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners to develop and improve services for people with liver disease. It sets out the Welsh Government’s requirement of NHS Wales and its partners to assess population need and plan the delivery of liver disease, to work to reduce the burden of liver disease, to deliver liver disease services to the highest possible standard, and to demonstrate improved outcomes for people with liver disease. It focuses on how to prevent the disease in the first instance and also, where necessary, to ensure people have access to excellent care, reaching across 6 themes. For each theme it sets out:

Delivery aspirations for the prevention and treatment of liver disease

Specific priorities to 2020

Responsibility to develop and deliver actions to achieve the specific priorities

Population outcome indicators and NHS assurance measures The vision: Our vision for the care for patients with liver disease is:

Before 2020 halt the rise in morbidity and mortality related to liver disease.

For NHS Wales to collaborate equally with its partners in social services and the third sector to provide seamless care to patients, where possible in the community.

For clinical leadership and multi-disciplinary working to help improve the quality of the patient pathway and drive down harm, waste and variation.

For better medical undergraduate, postgraduate and healthcare professional understanding of liver disease.

Patients responsible for their health, having an equal voice in their treatment and through the third sector having shared responsibility to determine the shape of services for liver disease.

We will use a range of indicators to measure success. These are a number of population outcome indicators and NHS assurance measures in the Liver Disease Delivery Plan. These will be developed further and refined over time. The Drivers:

Liver disease is typically asymptomatic, until often relatively late in disease progression when complications present. Consequently patients often present between 10 and 30 years after the first onset of their disease.1 This is particularly challenging because evidence suggests that modest changes in exposure to risk

1 Annual Report of Chief Medical Officer, Surveillance Vol., 2012. Department of Health.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/298297/cmo-report-2012.pdf


factors early-on in liver disease can lead to substantial improvement (or reversal of damage), in contrast to later presentation when prognoses are relatively poor.

The liver is the second largest organ in the body and it performs hundreds of complex functions including: fighting infections and illness; removing toxins (such as alcohol) from the body; controlling cholesterol levels; helping blood to clot; and releasing bile (a liquid that breaks down fats and aids digestion).

Many factors combine together to affect individuals liver health - in addition to individual lifestyle factors, wider determinants of health including genetics, the environment, living and working conditions, income, education and social networks. The most important behavioural risk factors of liver disease (and several other major causes of premature mortality, and morbidity in Wales) are unhealthy diet and physical inactivity leading to obesity, and harmful use of alcohol. Additionally with liver disease, blood borne viral infections (with hepatitis C or hepatitis B virus) are particular risks for certain groups, such as injecting drug users and those born in countries of high prevalence. Those with these infections may go on to develop chronic viral hepatitis, and hepato-cellular carcinomas.

There are many diseases that can affect the liver leading to chronic liver disease, cirrhosis, liver failure and potentially liver cancer. The main types of liver disease include:

Alcohol-related liver disease – where the liver is damaged after years of alcohol misuse.

Non-alcoholic fatty liver disease – a build-up of fat within liver cells, usually seen in overweight or obese people.

Viral Hepatitis – inflammation of the liver caused by a viral infection.

Autoimmune liver disease – where the body’s immune system attacks the liver cells (Autoimmune hepatitis) or bile ducts (Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis)

Inherited metabolic liver diseases such as Haemochromatosis, alpha-1 antitrypsin deficiency or Wilson’s disease – these disorders occur due to inherited abnormalities of metabolism leading to accumulation of abnormal products within the liver and lead to its damage.

Mortality2 rates for liver disease in the UK have increased 400% since 1970 and liver disease is now a common cause of death after cancer, heart disease, stroke and respiratory disease.3 It is also the third biggest cause of premature mortality in the UK and accounts for 62,000 years of working life lost per year across the UK. Admissions to hospital because of liver disease are increasing with most patients admitted with end-stage disease, liver cirrhosis or liver failure. This is primarily the result of an increase of excess alcohol consumption and an epidemic of obesity in the population but viral hepatitis also plays a major role in terms of the burden of end stage liver disease.

2 Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. (Roger Williams et al; Lancet; 2014; 384: 1953–97) 3 http://www.britishlivertrust.org.uk/about-us/media-centre/facts-about-liver-disease/

The prevalence of key risk factors associated with liver disease and its outcomes are linked to social deprivation and inequality. Obesity is an increasing challenge in all age groups and may become the main cause of liver disease in the future. The most recent report from the child measurement programme for Wales indicated in 2012-13 26% of children age 4-5 were overweight or obese. There was variation across Wales with 21% being overweight or obese in the least deprived parts of Wales and 29% in the most deprived areas. Failure to address this problem will lead to an increase in the burden of obesity-related liver disease in the future. There are also groups of individuals with higher risk of exposure to blood borne viral hepatitis who may have, or go onto develop, chronic viral hepatitis. The Welsh Government’s Blood Borne Viruses Action Plan for Wales 2010-2015 provides a strong platform for further efforts in this plan to tackle liver disease related to blood borne viruses and the associated risk factors. Prevalence of hepatitis C is known to be higher among some populations, for example injecting drug users and those born in countries of high prevalence. Many of these populations have higher prevalence for different reasons and targeted action in different communities and settings will be required. The Welsh Government's Substance Misuse Delivery Plan 2013-15 has helped to tackle unsafe injector practice and excessive alcohol consumption. What do we want to achieve? The Delivery Plan sets out action to improve outcomes in the following key areas between now and 2020:

Preventing liver disease

Timely detection of liver disease

Fast and effective care

Living with liver disease

Improving Information

Targeting research

2. ORGANISATIONAL PROFILE Organisational overview Cwm Taf Local Health Board was established on October 1st 2009 following the integration of the former Cwm Taf NHS Trust, Merthyr Tydfil Local Health Board and Rhondda Cynon Taf Local Health Board. In July 2013, the Health Board was awarded University Health Board status by the Minister for Health and Social Services and we became Cwm Taf University Health Board. Cwm Taf is made up of 4 localities – the Cynon Valley, Merthyr Tydfil, the Rhondda Valleys and the Taf Ely area. It is the second most densely populated Health Board in Wales, covering 3% of the landmass of Wales with approximately 295,135 residents. 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. Cwm Taf has a total income of around £600m and employs more that 8,000 staff. The age profile of our population is similar to Wales but with slightly higher proportions of persons aged under 5 years and in the 20-44 year age group, and slightly higher proportions of persons aged 60 and over. Overall the health of our population is improving however, within the Health Board we have areas of significant deprivation and far too many people still experience poor health. Many of the causes of poor health are difficult to tackle. Cwm Taf is an economically deprived area, with low levels of employment and educational attainment. These factors, along with other aspects of the physical environment, impact on the lifestyles of people living in the Health Board area. The Health Board has a very specific challenge in managing Liver Disease and has responded by remodelling the existing workforce in order to more effectively manage the service going forward. The management of liver disease is supported by 2 WTE Consultants with and interest in liver disease and form part of the wider 7.6 WTE Gastroenterology workforce. There are 2.6 WTE BBV Nurses who run clinics in five locations, cirrhosis surveillance and fibroscan services and day case ascites management. There is also support from 1 WTE Alcohol Liaison nurse. Overview of local health need and liver disease challenge The Health Board services the most deprived population in Wales, which is reflected in the lower life expectancy of its residents and a consequent greater need for health care. Life expectancy is the lowest of all Health Boards in Wales and our population can expect to have up to six more years of disability that the Welsh average. As a consequence the Health Board and Its partners provide care for a greater proportion of people’s lives, that there is a higher incidence of disease and that the prevalence of chronic conditions, including liver disease is higher than in other Health Boards. Hospital admissions because of liver disease are increasing with the majority of these patients admitted with end-stage disease, liver cirrhosis or liver failure. This is primarily as a result of increasing excessive alcohol consumption and obesity in the population with a contribution from viral hepatitis. The prevalence of key risk factors associated with liver disease and its outcomes are linked to social deprivation and inequality. Obesity is an increasing challenge in all age groups and there is concern that this will become a main cause for liver disease in the future. There are also groups of individuals with higher risk of exposure to blood borne viral hepatitis. Prevalence of Hepatitis C is higher in some populations, for example injecting drug users.

The following data published in the Public Health Wales Observatory publication ‘Data to support the Liver Disease Plan 2015’ (27 July 2015) their Welsh Health Survey lifestyle trends interactive tool; their ‘Alcohol and Health in Wales 2014 report’ and Centre of Communicable Disease Control output on blood borne virus infections provides the analysis on the health of Cwm Taf residents, the way in which they use our health services and their health related lifestyles. Liver Disease Population Needs Profile - A more detailed description on the demography and deprivation context within Cwm Taf can be found within our Liver Disease Population Needs Profile produced in August 2015. This document profiles liver disease in the Cwm Taf resident population and will aid the description of related population need. The work has informed the development of the Together for Health: Liver Disease Delivery Plan for Cwm Taf and must be considered alongside this plan. The production of the needs profile has encouraged an evidence-based approach in providing effective clinical care and addressing the wider determinants of (liver) health, to meet need.

As the Liver Disease Delivery Plan guidance is built around the following themes, for ease of reference, the structure of the needs assessment follows the same themes with information included where available

Delivery Theme

Detail

1 The risk factors contributing to liver disease are being actively addressed and fewer people are at risk of developing liver disease.

2 People with liver disease are detected early and referred for treatment.

3 People with liver disease receive appropriate care by specialist multi-disciplinary teams.

4 People with liver disease are supported to manage their condition and reduce the risk of their disease progressing.

5 NHS Wales and its partners provide better information and support to people at risk of developing or already suffering with liver disease.

6 Active collaboration in research related to liver disease delivers improvements in diagnosis, treatment and management.

Risk Factors for Liver Disease – theme 1

Obesity Adults Adults with a body mass index of over 30 are classed as obese. Cwm Taf is the Health Board with the highest proportion of adults who reported being obese - 27% in 2013/14 Welsh Health Survey and statistically significantly higher than the Wales average. There has been a gradual upward trend in obesity levels in Cwm Taf over the past decade, with the 2013/14 level being statistically significantly higher than that reported in the 2003/4-2004/5 survey.

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Cwm Taf UHB Wales

Percentage of adults reporting to be obese, age-standardised percentage, persons, Cwm Taf

UHB and Wales, 2003/04-2014Produced by Public Health Wales Observatory, using Welsh Health Survey (WG)

95% confidence interval

Similarly, the rates in local authority areas are significantly higher than the Wales average. Rhondda Cynon Taf reported the highest levels of obesity in Wales (30%, WHS, 2013/14), and Merthyr Tydfil 26%, against a Wales average of 23% in the same survey. Obesity levels in males in Cwm Taf shows a stable profile over recent times – with levels not statistically significantly higher than that reported in the 2003/4-2004/5 survey. In contrast, females in Cwm Taf reporting they are obese has gradually increased year-on-year (although not statistically significantly) since 2009/10, and levels in 2013/14 are statistically significantly higher than in 2003/4-2004/5.

Males (top graph) and Females (bottom graph) reporting being obese

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Percentage of adults reporting to be obese, age-standardised percentage, males, Cwm Taf



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Percentage of adults reporting to be obese, age-standardised percentage, females, Cwm Taf



The majority of our population categorised as obese (males and females), will have fatty liver disease, and many will have scarring and prolonged inflammation that will lead to cirrhosis. Obesity Children Obese children are more likely to be obese in adulthood, as well as experiencing adverse health and social consequences during childhood. The Millennium Cohort Study4 (specific to children in Wales) suggests there is an association between child obesity and obesity within their family. The report states that “having an obese mother increases the risk of a child being overweight or obese by 18 percentage points at age 5”. The authors suggest a genetic cause to this in part, but similarity of diet and activity within the family could also play a part. The same study also suggests that not being breastfed and/or weaning before the age of three months

4 Platt, L (Ed). (2014) “Millennium Cohort Study: Initial findings from the Age 11 survey” London: Centre for Longitudinal

Studies

increases the probability of a child becoming obese between the ages of three and five.

Data from the childhood measurement programme, 2013/14, that Cwm Taf has a (statistically) similar proportion of overweight or obese 4-5 year olds as Wales in total. However, in Merthyr Tydfil 32% of 4-5 year olds measured in 2013/14 were overweight or obese, which is statistically significantly higher than the Wales average of 26.5%. The distribution of overweight or obese 4-5 year olds in Cwm Taf is shown in below. Most notably this illustrates that three Middle (layer) Super Output Areas (MSOA) (administrative locations with between 2000 and 6000 households) have proportions of 4-5 year olds classed as overweight or obese in 2013/14 of between 35.3% and 38.2%, two in Rhondda Cynon Taf and one in Merthyr Tydfil Proportion of children who are overweight or obese, 3 years combined data, 2011/12, 2012/13 and 2013/14, children aged 4 to 5 years, Cwm Taf UHB

The All Wales Obesity Pathway was introduced in 2010 as a tool for Health Boards, working with local authorities and key stakeholders to map policies, services and cross departmental multi-agency activity for both children and adults, against minimum service requirements for four levels of intervention.

Figure 11: Obesity Pathway levels of intervention

In August 2014, a Welsh Government review of progress called for Health Boards to develop a timetabled action plan to address gaps in service provision in comparison to the minimum service requirements. An Obesity Pathway Needs Assessment to underpin this plan was published in December 2014 and sets out the strategic context around obesity services; provides information on the scale of obesity and outlines cost implications of obesity to Cwm Taf UHB. It also details current service provision against the four levels of the All Wales Obesity Pathway.

This needs assessment is available separately.

Alcohol Misuse

Alcohol misuse can cause Alcohol Related Liver Disease (ARLD) primarily in two ways - drinking a large amount of alcohol in a short amount of time (binge drinking) can cause fatty liver disease and, less commonly, alcoholic hepatitis, and drinking more than the recommended limits of alcohol over many years can cause hepatitis and cirrhosis, the more serious types of ARLD. Evidence suggests that people who regularly drink more than the maximum amounts of alcohol recommended are most at risk of developing ARLD. Between a fifth and a third of lifelong heavy drinkers develop cirrhosis, and a third of patients with alcohol-related liver disease have severe alcohol dependency.

http://www.nhs.uk/conditions/alcohol-misuse/Pages/Introduction.aspx

http://www.nhs.uk/Livewell/alcohol/Pages/Bingedrinking.aspx

http://www.nhs.uk/Conditions/Hepatitis/Pages/Introduction.aspx

http://www.nhs.uk/conditions/cirrhosis/Pages/Introduction.aspx

Trend in adult alcohol consumption above guidelines

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Percentage of adults reporting drinking above guidelines on a day in the past week, age-

standardised percentage, persons, Cwm Taf UHB and Wales, 2008-2014Produced by Public Health Wales Observatory, using Welsh Health Survey (WG)


The proportion of adults reporting consumption of alcohol above guidelines has not changed significantly over the recent past, and does not differ statistically from the all-Wales reported proportions. However, in 2013/14 this accounted for 41% (95%CI 39-44) of the respondent population. Alcohol specific hospital admissions rate (2012/13)

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Alcohol-specific hospital admissions (person-based), European age-standardised rate

per 100,000*, persons, all ages, Cwm Taf UHB and Wales, financial years 2003/04-2012/13

Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)


* Using the 2013 European Standard Population

The alcohol specific admissions rate for Merthyr Tydfil residents in this period was 383 per 100,000 people (EASR standardised) compared to a Welsh average of 339/100,000 people, however the 95% confidence interval includes the Wales average indicating the difference was not statistically significant. For Rhondda Cynon Taff residents the alcohol specific admissions rate in 2012/13 was 368/100,000 people, but the 95% confidence interval was higher than the Wales average, indicating this level is statistically significantly higher.

Another measure of the adverse effects of alcohol misuse is ‘alcohol attributable hospital admissions’ – this measures individuals admitted with alcohol-attributable conditions (either wholly or in part attributable to alcohol) at least once a year, either as the primary diagnosis (main reason) or a secondary diagnosis, whichever is most linked to alcohol, and is clearly captures data broader in nature than those presented in above. Alcohol attributable hospital admissions rate (2012/13)

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Alcohol-attributable hospital admissions (person-based, broad), European age-

standardised rate per 100,000*, persons, all ages, Cwm Taf UHB and Wales, financial years 2003/04-2012/13

Produced by Public Health Wales Observatory, using PEDW (NWIS), fractions (PHE) & MYE (ONS)


* Using the 2013 European Standard Population

The standardised (comparable) rates for alcohol attributable admission in Cwm Taf have increased in the past decade but have been statistically stable since 2007/8. Most recent data (2012/13) indicate there were 1212/100,000 persons alcohol attributable admissions in Cwm Taf, compared to Wales average of 1129/100,000 – statistically significantly different rates. In Rhondda Cynon Taff the comparable rate was 1197/100,000 and in Merthyr Tydfil 1275/100,000 – both statistically significantly higher than the Wales average. Hepatitis Establishing the prevalence of viral hepatitis (B and C virus) infection in the wider population is challenging mainly because chronic infection is largely ‘silent’, until complications occur. Estimates around hepatitis C virus (HCV) have been attempted (see below) and indicate an upward trend in numbers infected with the virus

Number of Welsh residents with HCV, and with HCC related to HCV 1997/1998 – 2009/10.

It is thought that the majority of those that are HCV infected are unaware they have the virus, or when/how they acquired it, and this plus a lengthy asymptomatic period adds to the spread of the virus. Hepatitis C Virus Number of Welsh residents with HCV, and with HCC related to HCV 1997/1998 – 2009/10

It is thought that the majority of those that are HCV infected are unaware they have the virus, or when/how they acquired it, and this plus a lengthy asymptomatic period adds to the spread of the virus.

The proportion of liver disease mortality causes by viral hepatitis remains low.5 However, because of the healthcare need and ongoing risk chronic carriers pose (in potentially unknowingly infecting others) a number of other metrics are worthy of noting here, to shape planning and assurance of treatment and care and to minimise risks. Hepatitis B Virus The numbers of those seen in clinic or service as new referrals with hepatitis B viral infection has fluctuated over the recent past.. Data collection systems have been under development during this period, so these data should be interpreted with caution. Numbers of new referrals seen in clinic/service with HBV, Cwm Taf, 2011/14 Source – PHW, Centre for Communicable Disease Control, 2015

Year Numbers of new referrals seen in clinic/service with HBV

2011 11

2012 44

2013 38

2014 9

From a slightly broader patient base – those seen by substance misuse services and at risk of blood bore virus should be offered testing for HBV infection (and HCV and HIV)and offered vaccination for hepatitis B, in line with NICE Quality Standard 23, Quality Statement 4. The proportion at risk and seen by the service who are fully vaccinated will offer an indication of need in terms of those that could be vaccinated (or at least offered vaccination) as primary prevention. Proportion of those at risk of BBV infection and seen by substance misuse services who are fully vaccinated against HBV infection. Source – PHW, Centre for Communicable

Disease Control, 2015

Detail 2014 2013 2012 2011No evidence of active HBV

infection or immunity 483 355Achieved vaccine induced

immunity to HBV 11 11Already fully vaccinated and

the level of vaccine immunity

was unknown 11 15Completed a course of hepatitis

B vaccinations 98 2Proportion of those at risk of

BBV infection and seen by

substance misuse services who

are fully vaccinated against

HBV infection

25% - 8% -

5 Annual Report of Chief Medical Officer, Surveillance Vol., 2012. Department of Health.



As above, the data collection systems utilised here have been under development during this period, data should be interpreted with caution. This proportion relates to the number of individuals who have been fully vaccinated, including those already known to have achieved vaccine induced immunity to HBV (numerator) and the number of individuals with a registered drug issue who had no evidence of HBV infection or immunity from prior infection (denominator). These data indicate a significant increase in the numbers completing a course of hepatitis B vaccinations, and those seen by service who are fully vaccinated.

Timely detection and referral (Theme 2)

Rates of Hospital Admissions for Liver Disease As noted above liver disease is typically asymptomatic, patients having few clinical signs of disease, making early detection very difficult. This is often accompanied with relatively late presentation with complications, and patients being admitted with late stage cirrhosis, bleeding varices, ascites and/or encephalopathy. Consequently assessing need at this stage of the pathway or ‘Theme 2 timely detection’ currently has to rely on hospital admissions data as the most robust source of information. Planning around timely detection might look to develop approaches to more timely detection of liver disease, through opportunistic identification in primary care; universal use of referral guidelines for abnormal liver function tests; blood borne virus screening, work with Alcohol Liaison Services and Emergency Departments to develop easy access to liver function testing; and increased knowledge of autoimmune and metabolic liver disease In 2013/14 Cwm Taf had the highest (Health Board) level of hospital admissions for Liver disease in Wales – 118.9/100,000 (all persons, all ages), compared to an all-Wales level of 91.4/100,000. This rate of admissions is statistically significantly higher than the Wales average and the levels in all other Health Boards. In relation to non-alcoholic fatty liver disease (NAFLD) specifically - whilst Cwm Taf has the second highest Health Board rate of hospital admissions (3.3/100,000 residents), this is not at a level statistically significantly different to the Wales average. Admissions due to alcoholic liver disease (50.7/100,000) however are statistically significantly higher than the Wales average (37.6/100,000), and equivalent to the highest levels in Wales. The dependence on hospital services is illustrated below.

Liver Disease Delivery Plan – Cwm Taf University Health Board

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Hospital admissions due to liver disease (all)

94.0 62.0 84.4 87.5 89.6 118.9 91.8

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff & Vale

UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Hospital admissions due to liver disease*, European age-standardised rate (EASR) per

100,000, all persons all ages, Wales health boards, 2013/14Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)

*ICD-10 codes B15-B19, C22, I81, I85, K70-K77 & T86.4 (principal diagnosis)

Wales = 91.4

Hospital admissions due to NAFLD

2.2 1.2 3.7 2.5 1.1 3.3 2.5

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB


UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

*ICD-10 code K76.0 (principal diagnosis)


Hospital admissions due to non-alcoholic fatty liver disease*, European age-

standardised rate (EASR) per 100,000, all persons all ages, Wales health boards, 2009/10-2013/14Produced by Public Health Wales Observatory, using PEDW (NWIS) and MYE (ONS)

Wales = 2.4


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Hospital admissions due to alcoholic liver disease

31.5 19.1 27.0 41.0 31.2 50.7 52.1

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB


UHB

Cwm Taf UHB Aneurin

Bevan UHB

Hospital admissions due to alcoholic liver disease*, European age-standardised rate

(EASR) per 100,000, all persons all ages, Wales health boards, 2011/12-2013/14Produced by Public Health Wales Observatory, using PEDW (NWIS) and MYE (ONS)


Wales = 37.6

*ICD-10 code K70 (principal diagnosis) Primary diagnoses (liver diseases), hospital admissions, including emergency admission proportion, length of stay and bed days, Cwm Taf, 2013/14.

Primary Diagnosis

Finished

Consultant

Episodes Male Female Admissions

Emergency

admissions

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admissions as

emergencies

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Mean

Length

of Stay BeddaysK76.0

Fatty (change of) liver 21 10 11 10 8 80 6 76

K70

Alcoholic liver disease 375 225 150 150 133 89 12 1,750

K74

Fibrosis and cirrhosis

of liver 34 14 20 16 8 50 19 230

Totals 430 249 181 176 149 85 - 2,056

The level of hospital admissions coded to certain liver diseases in Cwm Taf in 2013/14. Of 176 admissions, 149 (85%) were emergency admissions indicating the very late nature of the presentation for these diseases, and pointing toward the high cost of dealing with them. The clear majority of these emergency admissions were coded as alcoholic liver disease, and associated with an average length of stay of 12 days, totalling 1,750 bed-days in 2013/14.


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Primary diagnoses (cirrhosis types), hospital admissions, including emergency admission proportion, length of stay and bed days, Cwm Taf, 2013/14.

Primary Diagnosis

Finished

Consultant

Episodes Male Female Admissions Emergency

Proportion of

admissions as

emergencies

(%)

Mean

Length

of Stay Beddays

K703 - Alcoholic

cirrhosis of liver 64 52 12 30 26 87 12.2 324

K743 - Primary biliary

cirrhosis 8 * * 4 1 25 ** 39

K746 - Other and

unspecified cirrhosis

of liver 25 11 14 11 7 64 19.3 191

* denotes a suppressed value that is less than 3

** denotes a cell that has not been calculated due to low numbers (based on less that 10 values)

The guidance suggests rates of new diagnoses of cirrhosis, grouped by disease type would be a useful population outcome indicator, but these data are currently unavailable. Table 11 indicates finished consultant episode and admission data for the three ICD10 codes for cirrhosis, and limited to the most recent data available. These indicate alcoholic cirrhosis was the most commonly occurring form of cirrhosis in 2013/14 in Cwm Taf, with higher proportion of emergency admissions.

Fast & Effective Care -Theme 3

Patients with chronic liver disease suffer from high levels of morbidity as a consequence of either complications of cirrhosis or the development of liver cancer. The complications of cirrhosis often occur unexpectedly and can progress rapidly, consequently the is a need for patients to be seen within 24 hours of admission by someone with an appropriate level of specialist knowledge, due to the unique challenges patients with complications of cirrhosis may present.

Some patients whose liver disease has an irreversibly progressive course may benefit from a liver transplant. At present, both rates of referral and rates of liver transplantation for residents in Wales are lower than expected for the population size.

Liver Disease Mortality

In terms of premature mortality (20 to 75 year olds) from chronic liver disease – The graph below shows a downward trend in Cwm Taf since 2007/9 to the point of no statistically significant difference to the all Wales level in 2011/13.


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Cwm Taf, Premature mortality from chronic liver disease

In those over 75years, a different trend for mortality, from chronic liver disease, in Cwm Taf, is illustrated in Figure 25, but essentially this is not statistically significantly different from the Wales average over the past decade. Chronic liver disease premature mortality

Cwm Taf, mortality from chronic liver disease, over 75y

By way of comparison to other areas for premature mortality (under 75years) from chronic liver disease, Figure 25 shows that in the most recently available data period (2009/13), Cwm Taf had the highest overall (premature) mortality


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rate (16.9/100,000 population), and this was statistically significantly higher than the all Wales level (13.8/100,000 population). The overall rate of mortality is higher in males than females (19.9/100,000(male) and 14.1/100,000(females). The Cwm Taf rate for males is not statistically significantly different from the Wales average, whereas the female level in Cwm Taf is the highest in Wales and statistically significantly higher than the Wales average. Cwm Taf has a higher rate of women dying prematurely because of chronic liver disease than any other area in Wales.

14.3 7.6 11.0 15.0 13.9 16.9 14.1

Mortality from chronic liver disease including cirrhosis*, European age-standardised

rate (EASR) per 100,000, males, females and persons aged under 75, Wales health boards, 2009-13Produced by Public Health Wales Observatory using PHM & MYE (ONS)


Wales = 13.8

Persons

18.2 9.5 13.9 20.6 19.9 19.9 17.7

Wales = 17.9

Males

10.6 5.9 8.2 9.8 8.1 14.1 10.6

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff &

Vale UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Wales = 9.9

*ICD-10 codes K70, K73 & K74 (underlying cause)

Females


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Paracetamol Overdoses

Paracetamol overdose can result in liver damage which may be fatal.

Paracetamol overdose hospital admissions

128.6 73.7 95.0 97.8 130.4 118.3 100.8

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff &

Vale UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Hospital admissions due to paracetamol overdose*, European age-standardised rate

(EASR) per 100,000, all persons all ages, Wales health boards, 2013/14Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)


Wales = 110.5

*Paracetamol overdose has been identified using ICD-10 codes T39.1 and either X40 (accidental poisoning) or X60 (intentional poisoning) occuring on the admitting episode of care (any diagnosis position)

The table above indicates that in 2013/14 there were 118.3/100,000 population admissions due to paracetamol overdose in Cwm Taf – a level statistically comparable to the Wales average. Paracetamol overdose hospital admissions are identified when ICD-10 codes T39.1 and either X40 (accidental poisoning) or X60 (intentional poisoning) occur on the admitting episode of care, in any diagnosis position.

Intravenous acetylcysteine is the antidote to treat paracetamol overdose and is virtually 100% effective in preventing liver damage when given within 8 hours of the overdose. After this time efficacy falls substantially, affording only a very limited window of time in which to successfully prevent serious hepatotoxicity


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Hepatocellular carcinoma incidence and mortality (counts) Incidence of HCC has seen a doubling in Western Countries since 1983, primarily because of the increase in hepatitis C viral infection, with the incidence of HCV related HCCs projected to treble in Western Countries in the next 20 years (Davis et al, 2003). It accounts for around 85% of all hepatomas and is the most common primary liver cancer, causing around 1500 deaths per year in the UK. Several factors influence the risk of HCC development including gender (much greater risk of development in males); age (with incidence increasing with advancing age and peaking at 70 years (EASL, 2010)), presence of hepatic cirrhosis and the aetiology of an individual’s liver disease. In Cwm Taf, there has been an overall upward trend in the crude number of cases of HCC since 2006, with an average of 16 diagnoses per year. There is no apparent trend in either direction in relation to associated mortality, with an average of 12 deaths per year in Cwm Taf. Both incidence and mortality data presented here are crude counts, and are very small numbers, so caution is need in their interpretation.

0

5

10

15

20

25

2006 2007 2008 2009 2010 2011 2012 2013

Co

un

t

Hepatocellular carcinoma incidence and mortality

(counts), Cwm Taf, 2006-13. Source: Wales Cancer Surveillance and Intelligence Unit.

Incidence

Mortality


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Liver transplant procedures

0.6 0.7 0.9 0.8 0.9 0.8 0.8

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff &

Vale UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Wales = 0.8


Liver transplant procedures*, European age-standardised rate (EASR) per

100,000, persons all ages, Wales health boards, 2004/05-2013/14 Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)

*OPCS code J01 (any mention)

Liver transplantation is usually recommended when the patient has end-stage liver disease and only considered if it is highly likely that a patients expected lifespan would be shorter than normal, or quality of life so poor as to be intolerable;, and it is expected that the patient would have at least a 50% chance of surviving for at least five years after the transplant with an acceptable quality of life. There are exceptions to these heuristics for example, continuing misuse of alcohol, or presence of liver cancer metastases.

Referral to treatment Referral to treatment times – In June 2015, 1024 Cwm Taf residents, coded to gastroenterology, was waiting to start treatment. Of these 918 (89.6%) were waiting up to 26 weeks, 100 between 26 and 36 weeks, and 6 (0.58%) over 36 weeks.

Living with liver disease (Theme 4)

Life lost to liver disease (alcohol)

An estimate of the increase in life expectancy at birth which would be expected if all alcohol-related deaths among males/females aged less than 75 years were prevented is given below. Cwm Taf has the highest level of life lost due to alcohol at 18.1months for males and 8.1months for females


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Months of life lost due to alcohol, males

13.1

11.7

11.7

15.3

13.2

18.1

12.4

Wales = 13.5

Betsi Cadwaladr UHB

Powys tHB

Hywel Dda UHB

ABM UHB

Cardiff & Vale UHB

Cwm Taf UHB

Aneurin Bevan UHB

Months of life lost due to alcohol, males aged under 75, Wales health boards,

2010-2012

Produced by Public Health Wales Observatory, using ADDE, Life Tables for Wales & MYE (ONS)

Months of life lost due to alcohol, females

6.9

6.1

5.9

6.7

6.0

8.1

5.8

Wales = 6.5

Betsi Cadwaladr UHB

Powys tHB

Hywel Dda UHB

ABM UHB

Cardiff & Vale UHB

Cwm Taf UHB

Aneurin Bevan UHB

Months of life lost due to alcohol, females aged under 75, Wales health

boards, 2010-2012

Produced by Public Health Wales Observatory, using ADDE, Life Tables for Wales & MYE (ONS)


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Conclusions of Needs Assessment

- Cwm Taf has the highest chronic liver disease premature mortality rate in Wales, based on the most recent data (2009/13).

- In 2013/14 Cwm Taf had the highest level of hospital admissions for liver disease in Wales. The rate of admissions was statistically significantly higher than the Wales average and the levels in all other Health Boards.

- Admissions for non-alcoholic fatty liver disease (NAFLD) were not statistically significantly different to the Wales average, but admissions due to alcoholic (related) liver disease (ARLD) were statistically significantly higher than the Wales average, and equivalent to the highest levels in Wales.

- In 2013/14 85% of hospital admissions for NAFLD, ARLD and fibrosis/cirrhosis, were emergency admissions. The majority were coded as alcoholic liver disease, and totalled 1,750 bed-days.

- There are encouraging signs in relation to alcohol consumption – notably in Merthyr Tydfil where the proportion of males respondents to the Welsh Health Survey reporting binge pattern drinking dropped from 39% in 2008/9 to 28% in 2013/14. - Obesity levels in Cwm Taf are increasing and, as has been the case since 2002/3, remain statistically significantly higher than the Wales average. It is estimated that there are 62,400 individuals with a BMI over 30, in Cwm Taf, and 13.4% of our 4 and 5 years olds were also classed as obese, when measured in 2013/14.

- Levels of demand for specialist assessment for hepatitis C virus (HCV) infection and numbers starting treatment because of infection did not change across Cwm Taf between 2011 and 2014. Whilst the proportion of those at risk of blood borne viruses and seen by substance misuse services, and who are tested for HCV increased from 28% in 2012 to 71% in 2014.


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3. DEVELOPMENT OF CWM TAF UHB LOCAL DELIVERY PLAN

LIVER DISEASE In response to the “Together for Health – Liver Disease Delivery Plan” (2015), Health Boards are required, together with their partners, to produce and publish a detailed local service delivery plan. The Blood Borne Viruses Action Plan for Wales 2010-2016 and the Substance Misuse Delivery Plan 2013-15 have provided a strong platform for tackling blood borne viral hepatitis as a leading cause of liver disease. There is also important related work contained in the All Wales Obesity Pathway and other delivery plans covering Sexual Health, Stroke, Heart Disease, Diabetes, Cancer, the Critically Ill, End of Life Care and Organ Donation. This work will continue, and where relevant link across to this plan to tackle the burden of liver disease.. Important contributions to tackling liver disease have been made by the British Society of Gastroenterology in its reports: the National Plan for Liver Services UK (2009) and Alcohol Related Disease (2010); as well as the 2014 Lancet report ‘Addressing Liver Disease in the UK’. A number of challenges in the provision of specialist care were also highlighted in the 2013 UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report into alcohol-related liver disease deaths. Liver disease is typically asymptomatic, patients having few clinical signs of disease, making early detection very difficult. This is often accompanied with relatively late presentation with complications, and patients being admitted with late stage cirrhosis, bleeding varices, ascites and/or encephalopathy The health board Executive Lead for liver disease will report progress formally to their Boards against milestones in these delivery plans and publish these reports on their websites at least annually. Following the analysis of the specific liver disease related need assessment it is clear that Cwm Taf face a significant challenge in managing the current demands and most specifically in the area of health promotion and prevention. 4. SUMMARY OF THE PLAN - THE PRIORITIES TO 2020 Following the completion of our local population needs assessment, the key findings have been incorporated into our local delivery plan for liver disease. This delivery plan includes actions against each of the priorities within the Welsh Government’s Liver Disease Delivery Plan (2015) and to the challenges that have arisen through our population needs analysis. It is clear that with such issues that span a spectrum of services he Heath Board needs to establish a formal Liver Disease planning and delivery group consisting of:


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Drs and Specialist Nurses in secondary care

Drs and Specialist nurses in the Control of Drug and Alcohol team

Public Health

3rd sector

Primary Care liver disease champions for each locality Prevention and early detection are key to changing the profile of liver disease in Cwm Taf with obesity and Alcohol primary prevention high on the agenda. Preventing liver disease The priorities within the national plan adopted by CTUHB are to:

1. Work with the Public Health Wales Health Improvement Programme to ensure appropriate effort is allocated to reducing the risk factors for liver disease and programmes reflect the potential contribution to reducing liver disease. This work should include optimisation of services and strategies for the primary prevention of liver disease, as well as increasing awareness of liver disease throughout the pathway and related pathways.

2. Take forward the legacy of the Blood Borne Virus Hepatitis Action Plan

in all relevant settings and continue the effort to eradicate viral hepatitis; including working to identify and treat individuals with a diagnosis of hepatitis B or C infection and working with the Welsh Health Specialised Services Committee and All Wales Medicines Strategy Group on the phased introduction of new hepatitis C drugs. WHSSC does not currently commission or fund hepatitis- eradicating drugs and these remain the HB’s responsibility. A statement from Welsh Government regarding the access arrangements is awaited.

3. Further develop the opportunistic assessment of alcohol intake in

different settings and develop in house alcohol care teams within health boards to provide timely interventions as appropriate; including helping to take forward the systematic process for reviewing alcohol-related deaths and make recommendations about how Substance Misuse Services and Alcohol Liaison Services can better assist the management of risk factors for liver disease.

4. Examine opportunities and make costed recommendations to increase

the availability of targeted community testing for viral hepatitis and fatty liver disease particularly in areas of socio-economic deprivation to address health inequity; including the community availability of non-invasive testing (NITs) for liver fibrosis among high risk populations.

5. Continue to review and monitor the content of the online over-50s

health and wellbeing assessment Add to your Life in relation to risk factors for liver disease.


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6. Develop an approach to help de-stigmatise liver disease. Plus the following locally derived priorities for Cwm Taf:

7. Ensure full engagement across the Health Board on management of pathways for the management of obesity.

8. Strengthen Alcohol Liaison nurse services.

9. Utilise locality networks that are delivering obesity services and include

an alcohol reduction strand. 10. Work towards the implementation of the Public Health Wales strategies

as outlined in the Cwm Taf response to Working Together to Reduce Harm.

11. Strengthen links between Statutory (CDAT) and 3RD sector delivery of

substance misuse services with a unified governance structure Timely detection of liver disease The priorities with the national plan adopted by CTUHB are to: 1. Improve provision of assessment and testing of those at highest risk of

developing liver disease. 2. Improve awareness and understanding of liver disease among primary and

community care, and local government partners to help detect early liver disease and make appropriate referral.

3. Develop a nationally agreed care pathway for patients with abnormal liver

function tests and develop a national audit to support this. 4. Develop a nationally agreed care pathway for the risk assessment of those

incidentally found to have fatty liver disease. 5. Develop nationally agreed referral guidelines to improve consistency and

quality in referral practices, manage demand and minimise inappropriate investigation of those at low risk. This will include appropriate links to guidance and related care pathways and service frameworks.

6. Develop a costed proposal for identifying those at greatest risk of fatty liver

disease. 7. Encourage primary care clusters/locality groups to identify a champion for

liver disease who will work with the health board liver disease team to improve risk management, detection and referral practices.


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8. Undertake a cost assessment of improving the effectiveness of the routine use of risk assessment tools (such as routine provision of AST/ALT ratio) to identify those at greatest risk of significant liver disease.

Plus the following locally derived priorities for Cwm Taf: 9. Measure performance against key standards in the developed national

audit of the care pathway for the investigation and management of abnormal Liver Function Tests, across primary and secondary care.

10. Strengthen the role of the alcohol liaison nurse to allow the delivery of

Alcohol Brief Intervention. 11. Continue working with all tiers of substance services to ensure Dry Blood

Spot Testing (DBST) of clients with injecting drugs. 12. Implement the pathway for abnormal liver test which has been developed. 13. Provide training for cluster liver disease champions. Fast and effective care The priorities with the national plan adopted by CTUHB are to: 1. Plan to establish a liver disease unit in each health board staffed by at

least one consultant hepatologist supported by additional consultant hepatologists or gastroenterologists with appropriate training in managing liver disease. Each unit should provide support to primary care clusters and through a hub and spoke arrangement support neighbouring hospitals to facilitate high quality inpatient care.

2. Health boards review liver disease pathways, including adoption of the

BSG/BASL care bundle for decompensated cirrhosis patients, and take forward work to optimise the pathway efficiency and link to related pathways.

3. Health board liver disease units to work with WAGE to meet common

standards and meet routinely to share best practice and assess performance against standards.

4. Improve access to related services such as diagnostics (particularly

fibroscan and biopsy, including transjugular biopsy), dietetics and interventional radiology.

5. The Health Board will work with WHSSC to develop proposals to

commission responsive services for patients who require liver transplantation or who have suspected hepatocellular carcinoma. This will be managed through the Liver Disease implementation group and the proposals will be considered for approval by the WHSSC joint committee.


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6. Implementation group to support access to national or regional hepatocellular carcinoma Multi-Disciplinary Teams.

Plus the following locally derived priorities for Cwm Taf: 7. Scope out and fully understand the required resource to deliver a liver

disease unit. 8. Identify time for lead clinicians to develop and implement robust pathways

across the health community designed to deliver a consistent approach to liver disease management.

9. Continue with engagement at the All Wales BBV network meetings. 10. BBV leads have an agreed standard supporting the implementation of

prescribing appropriate treatments in line with NICE and AWMSG guidance fr the management of viral hepatitis. This needs to be agreed on a national level.

Living with liver disease The priorities with the national plan adopted by CTUHB are to: 1. Facilitate the strengthening of the co-productive approach to designing

services and treatment plans. 2. Consider the feasibility of developing one-stop-shop cirrhosis clinics where

patients can have their disease monitored and surveillance ultrasound scans undertaken as appropriate.

3. Examine opportunities to encourage and support better primary care

management of those diagnosed with liver disease including improved uptake of appropriate vaccinations.

4. Improve access to specialist dietetic advice and psychological support,

especially for patients with cirrhosis and chronic liver failure so that they can better self-manage their condition.

5. Support the provision of palliative care services for patients with chronic

liver failure. 6. Encourage each health board to engage community support groups to

help patients manage their condition in the community. 7. Establish strong links with National liver charities. 8. Strengthen patient participation groups in relation to liver disease.


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Plus the following locally derived priorities for Cwm Taf: 9. Continue with and review the outcomes of the Cirrhosis Surveillance

Clinics – to include patient feedback. 10. Ensure understanding across all providers of the planning requirements for

patients on an end of life pathway. 11. Work with palliative care services to include liver disease.

12. Improve the provision of psychiatric liaison nurses to provide intensive input for patients with advanced liver disease and alcohol related brain impairment.

Improving Information The priorities with the national plan adopted by CTUHB are to: 1. Review the quality of existing data systems for the reporting of liver-related

morbidity, mortality and associated risk factors and make recommendations for improvement.

2. Develop a clinical management system to support the care of individuals

with chronic liver disease, provide measurement of health outcomes and support high quality audit and research.

3. Develop information to increase public awareness of risks factors related

to these conditions in a way which is specific and relevant to each of the at risk communities; this work must have as its focus the de-stigmatisation of liver disease and its causes.

4. Develop national management guidelines facilitating the assessment of

individuals with abnormal LFTs; these should include guidelines for the management of common complications of liver disease and indicators for referral.

5. Develop and implement electronic alerts for patients with abnormal liver

function tests linked to national pathway guidance directing the requesting clinician to advise on further investigation and, if necessary onwards referrals to specialist services.

6. Health boards work to increase awareness of relevant educational material

for staff (e.g. RCN liver disease toolkit, RCGP online resource on Hepatitis B and C: Detection, Diagnosis and Management).Increase provision of medical and nursing training in hepatology and introduce wider educational opportunities for clinicians to increase awareness of liver disease, its risk factors and symptoms.


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7. To develop the delivery plan set of measures in order to understand the current situation and the size of the issue, including:

Identify existing care pathways for the investigation and management of chronically elevated LFTs and map local provision of services.

Establish the number of people diagnosed with cirrhosis in each health board.

Establish and report the waiting time measures for patients referred for outpatient specialist assessment.

Collated data on admissions related to liver disorders

Estimated number of years of life lost from liver disease in Wales.

Geographical deprivation gaps for liver disease morbidity and mortality.

Plus the following locally derived priorities for Cwm Taf: 8. Establish links to local and national charities. 9. Develop a performance dashboard specifically for liver disease and the

priorities identified within this plan.

Targeting Research The priorities with the national plan adopted by CTUHB are to: 1. Undertake a gap analysis and identify key pieces of research needed and

work with NISCHR to develop opportunities to address such gaps. 2. Explore the utilisation of data linkage to better understand liver disease

and its risk factors. 3. Establish a database for liver disease to facilitate all Wales research and

funding; including mechanisms for the application of research findings. 4. Explore undertaking research into methods for improving surveillance

strategies in hepatocellular carcinoma. 5. Explore undertaking research into the relationship between lifestyle

choices and liver disease and how these can be tackled. 6. Assess the impact of the “Have a Word” brief intervention training

programme. 7. Increase the number of joint academic appointments between health

boards and local universities. 8. Ensure local data is shared across the liver disease network for joint

learning


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5. PERFORMANCE MEASURES/MANAGEMENT The Welsh Government’s Liver Disease Delivery Plan (2015) contains an outline description of the national metrics that health boards 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.

Indicators and assurance measures will be further developed by the All Wales Liver Disease Implementation Group. Progress with these outcome indicators will form the basis of each health board’s annual report on liver disease. They will be calculated on behalf of the NHS annually at both a national and health board population level. Health boards will produce annual progress reports starting in April 2016. Health boards will also report progress against the local delivery plan milestones to their Boards at least annually and to the public via their websites. It is expected that Local Delivery Plan and their milestones are reviewed and are updated annually from August 2015.


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Action Plan Note: This action plan reflects the locally derived additional priorities identified by CTUHB. The national priorities included in this

Plan will also form the basis of the work programme to be taken forward both at a national level and local by the Liver Disease Planning and Delivery Group and relevant sub groups when established. This action plan is work in progress and will be further

developed throughout 2015/16. Timescales and further actions/outcomes to addressed the Planning & Delivery Group.

Preventing liver disease

Local Priority Actions Expected outcome Risks to delivery Timescales / Milestones

Lead

Ensure the full engagement of the HB on the management of pathways for the management of obesity.

Ensuring full engagement.

2015 and ongoing Prevention Sub Group

Strengthen Alcohol Liaison nurse services.

Financial constraints.


Utilise locality networks that are delivering obesity services and include an alcohol reduction strand.


Work towards the implementation of the Public Health Wales strategies as



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outlined in the CTUHB response to Working Together to Reduce Harm.

Strengthen links between Statutory (CDAT) and 3rd sector delivery of substance misuse services with a unified governance structure.


Timely detection of liver disease


Lead

Measure performance against key standards in the developed national audit of the care pathway for investigation and management of abnormal LFTs, across primary and

2015 and ongoing. Timely Detection/Fast Effective Care Sub Group.


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secondary care.

Strengthen the role of the alcohol liaison nurse to allow the delivery of Alcohol Brief Intervention.


2015 and ongoing. Timely Detection/Fast Effective Care Sub Group

Continue working with all tiers of substance services to ensure Dry Blood Spot Testing (DBST) of clients injecting drugs.

Ongoing. Improved service provision.

Required engagement of all tiers.

2015 and ongoing. Timely Detection/Fast Effective Care Sub Group

Implement the pathway for abnormal liver test which has been developed.

As described. Improved service provision.

Any financial constraints identified.


Provide training for cluster liver disease champions.

As described. Improved integration of services across primary and secondary care. Improved service provision.

Identification of cluster liver disease champions. Staff release for training.



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Fast and effective care


Lead

Scope out and fully understand the required resource to delivery a liver disease unit.

Undertake a scoping exercise.

Restriction on lead clinicians time.

2015 and ongoing. Clinical Lead for Liver Disease.

Identify time for lead clinicians to develop and implement robust pathways across the health community designed to deliver a consistent approach to liver disease management.

Commence directorate discussions.

Pathways developed and implemented across the health community which will improve service provision for patients.

Identification of lead clinicians time. Financial constraints.

2015 and ongoing. Directorate for Acute Medicine & A & E

Continue with engagement of the all Wales BBV network meetings.

Continued attendance.

Improved service provision.

Time commitment for engagement.

Ongoing. Clinical Lead for Liver Disease.

BBV leads have an agreed standard supporting the implementation of prescribing

As described. 2015 and ongoing. National Delivery Group.


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appropriate treatments for the management of viral hepatitis. This needs agreement on a national level.

Living with liver disease


Lead

Continue with & review the outcomes of the Cirrhosis Surveillance Clinics – to include patient feedback.

Timescales for review to be put in place.

Improved patient care derived from patient feedback and implementation of actions from the audit.

Any financial constraints associated with service improvement.


Ensure understanding across all providers of the planning requirements for patients on an end of life pathway.

To be determined. Improved care for patients with liver disease who are end of life.

Engagement of all providers.


Work with palliative To be determined. Improved care for Any financial 2015 and ongoing. Timely


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care services to include liver disease.

patients with liver disease who are end of life.

constraints/ capacity issues.

Detection/Fast Effective Care Sub Group.

Improve the provision of psychiatric liaison nurses to provide intensive input for patients with advanced liver disease and alcohol related brain impairment.

To be determined. Improved service provision for patients with advanced liver disease and alcohol related brain impairment.


Identified as a priority at a national level to be taken forward during 2015.

Timely Detection/Fast Effective Care Sub Group.

Improving information


Lead

Establish links to local and national charities.

Commence with inviting representation from charities on Planning & Delivery Group.

Improved patient care.

Successful engagement with charities.

2015 and ongoing. Timely Detection/Fast and Effective Care Sub Group.

Develop a performance dashboard specifically for liver

Performance dashboard to be developed.

Improved planning and delivery. Improved monitoring and

Identification of the support and expertise required to develop the

2015 and ongoing. Timely Detection/Fast and Effective Care Sub Group


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disease and the priorities identified within this plan.

reporting. Measureable improvement to delivery this Plan.

dashboard.

Targeting research

Priority Actions Expected outcome Risks to delivery Timescales / Milestones

Lead

No local priorities identified for this theme. Therefore the implementation of this theme will be based around the national priorities as described in this plan.

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