ABUHB Liver Disease Delivery Plan 2015-2020 1. … Liver Disease... · Sclerosing Cholangitis)...

ABUHB Liver Disease Delivery Plan 2015-2020

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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: 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). 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:


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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.

Mortality1 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.2 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. 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.

1 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) 2 http://www.britishlivertrust.org.uk/about-us/media-centre/facts-about-liver-disease/


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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 The ABUHB liver service is provided under the auspices of the Gwent Liver Unit, which sits within the Department of Gastroenterology and Hepatology in the Unscheduled Care Division. The workforce currently comprises 2 substantive consultant Hepatologists (spend more than 50% of their time dedicated to the care of liver disease). Both consultants are based on the Royal Gwent Hospital (RGH) site. The consultant who provided liver care to patients admitted to Nevill Hall Hospital (NHH) and saw outpatients within that locality left in December 2014 and has not been substantively replaced although a locum is in place from September 2015. Furthermore the senior consultant on the RGH site who contributes to the care of liver inpatients and undertakes some outpatient work has delayed retirement due to the recent inability to recruit to the post based at RGH. The service is supported by 2 Hepatology Nurse specialists (one funded by the BBV plan), a community Blood Borne Virus (BBV) nurse and a Community Psychiatric Nurse (CPN). In addition Advanced Nurse Practitioners within Gastroenterology on both the RGH and NHH site support the medical teams in management of complex liver disease (abdominal drains predominantly). The service is further supported by diagnostic and interventional radiology and by the intensive care units at RGH and NHH. Waiting times for new and follow up appointments are longer than required across the health board for Gastroenterology patients and data has proven difficult to obtain for Liver specific referrals and this is an informatics issue that will need to be addressed. Despite workforce limitations the liver service provides a wide array of diagnostic and therapeutic options for patients with liver disease. The Liver Unit was the first in Wales to have a Fibroscan and the first to have an portable Fibroscan for use prisons and remote sites. In addition to a full array of relevant diagnostic tests (including transjugular liver biopsy which is not universally available) the Gwent Liver Unit is the only centre in Wales able to offer both radiofrequency ablation (RFA) and trans arterial


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chemoebolisation (TACE) for patients with primary liver cancer. The ability exists within the Liver Unit to also offer TIPS procedures to control bleeding or fluid overload in liver disease but is not currently financially supported. Inpatients on the RGH site are managed by dedicated Hepatologists although the same is not true at NHH though planned centralisation of this service is implicit within the Clinical Futures model. For outpatients, selected stable patients with cirrhosis are managed by the Specialist nurses and a HCC surveillance programme is in operation but requires a more formalised approach (automatic recall system not in place). Fully dedicated liver clinics do not currently exist though the Monday County clinic is attended by the 2 RGH Hepatologists and the NHH locum and this provides the possibility to fully ring fence these clinics for patients with liver disease. Overview of local health need related to liver disease prevention and service provision This needs profile is based on the data provided by the Public Health Wales Observatory in support of local Liver Disease Plans. The profile is split into three sections: lifestyle indicators, hospital activity and mortality indicators. We have included charts here to illustrate the most notable points, with the remainder in Appendix 1 for reference. 1. Lifestyle indicators

Adult obesity

The latest Welsh Health Survey data indicates 25% of adults in Aneurin Bevan

University Health Board (ABUHB) area are obese (report height and weight

equivalent to a Body Mass Index (BMI) of 30+).

This percentage is significantly higher than the all Wales average (22%) and

shows an upwards trend since 2003/04 (see Figure 1).

The boroughs of Caerphilly (28%), Blaenau Gwent (29%) and Torfaen (27%) in

particular are significantly higher than the Wales average, with Newport at 23%.

Monmouthshire is the only authority in ABUHB that is significantly lower than the

Wales average (18%).


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Figure 1: Trend in adult obesity in ABUHB, 2003/04 - 2014

Source: Public Health Wales Observatory, 2015. Welsh Health Survey lifestyle trends 2015. Child obesity

Data from the Child Measurement Programme for Wales (2013/14) shows that

26% of children aged 4 to 5 years in the ABUHB area are overweight or obese.

This is similar to the Welsh average, but significantly higher than any region in

England, where the highest prevalence is 24%.

The proportion of children who are overweight or obese broadly reflects the data

for adults discussed above, ranging from 23% in Monmouthshire to 28% in

Blaenau Gwent.

Torfaen (27%), Caerphilly (27%) and Newport (26%) are also equal to or higher

than the ABUHB average.

Source: Public Health Wales, 2015. Child Measurement Programme for Wales 2013/14

0

5

10

15

20

25

30

2003/0

4-

2004/0

5

2004/0

5-

2005/0

6

2005/0

6-

2007

2007-2

008

2008-2

009

2009-2

010

2010-2

011

2011-2

012

2012-2

013

2013-2

014

Aneurin Bevan UHB Wales

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

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

95% confidence interval


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Months of life lost due to alcohol misuse This is an estimate of the increase in life expectancy at birth that would be expected if all alcohol-attributable deaths among persons aged under 75 years were prevented. The number of months lost due to alcohol is 12.4 for males and 5.8 for females in the ABUHB area. The average for Wales is 13.5 for males and 6.5 for females. Source: Public Health Wales Observatory, 2014. Alcohol and Health in Wales Profile 2. Hospital Activity

Hospital admissions due to non-alcoholic fatty liver disease

In the ABUHB area, the admission rate due to non-alcoholic fatty liver disease (NAFLD) is 2.5 per 100,000, which is similar to the all Wales average and third highest in Wales (Appendix 1: Figure 2). Hospital admissions due to alcoholic liver disease

In the ABUHB area, the admission rate due to alcoholic liver disease is 52.1 per 100,000, which is the highest in Wales and significantly higher than the Welsh average. Figure 3: Hospital admissions due to alcoholic liver disease, 2011/12 - 2013/14

Source: Public Health Wales Observatory 2015, Data to support the Liver Disease Plan 2015

31.5 19.1 27.0 41.0 31.2 50.7 52.1

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff & Vale

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)


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Alcohol-specific hospital admissions (all ages)

There were 2,126 people admitted with an alcohol-specific condition either in the

primary or secondary diagnosis in the ABUHB area during 2012/13.

ABUHB has the highest rate of alcohol-specific hospital admissions in Wales,

significantly higher than the all Wales average (see Figure 4).

There are more males than females admitted with an alcohol-specific condition,

but the rates for both are significantly higher than the average for Wales.

The rate of alcohol-specific hospital admissions has been trending upwards in the

ABUHB area and has been significantly higher than the Wales average since

2009/10, although there is an indication of this gap starting to decrease in

2012/13 (see Figure 5).

Figure 4: Alcohol-specific hospital admissions, 2012/13

Source: Public Health Wales Observatory, 2014. Alcohol and Health in Wales Profile

358

242

306

324

327

371

376

Wales = 339

Betsi Cadwaladr UHB

Powys tHB

Hywel Dda UHB

ABM UHB

Cardiff & Vale UHB

Cwm Taf UHB

Aneurin Bevan UHB

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

standardised rate per 100,000*, persons, all ages, Wales health boards, financial year 2012/13Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)

* Using the 2013 European Standard Population



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Figure 5: Trend in alcohol-specific hospital admissions, 2003/04 – 2012/13

Source: Public Health Wales Observatory, 2014. Alcohol and Health in Wales Profile Alcohol-specific hospital admissions (under 18)

On average, 88 people aged under 18 were admitted annually in ABUHB with an

alcohol-specific condition during the period 2010/11 – 2012/13.

The ABUHB rate is not significantly higher than the all Wales average (see Figure

6), but it should be noted that Wales has a significantly higher alcohol-specific

admission rate (under 18) than that observed in England.

In this age group there are more females than males admitted with an alcohol-

specific condition.

The rate of alcohol-specific hospital admissions for under 18s has been trending

downwards in the ABUHB area since the period 2005/06 – 2006/07, with the gap

between the Health Board and Wales rates closing (see Figure 7).

0

50

100

150

200

250

300

350

400

450

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13


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

per 100,000*, persons, all ages, Aneurin Bevan 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


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Figure 6: Alcohol-specific hospital admissions (under 18), 2010/11 – 2012/13

Source: Public Health Wales Observatory, 2014. Alcohol and Health in Wales Profile Figure 7: Trend in alcohol-specific hospital admissions (under 18), 2003/04 – 2012/13

Source: Public Health Wales Observatory, 2014. Alcohol and Health in Wales Profile

76

50

85

52

30

87

70

Wales = 65

Betsi Cadwaladr UHB

Powys tHB

Hywel Dda UHB

ABM UHB

Cardiff & Vale UHB

Cwm Taf UHB

Aneurin Bevan UHB

Alcohol-specific hospital admissions (person-based), crude rate per 100,000,

persons aged under 18, Wales health boards, financial years 2010/11-2012/13Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)


0

20

40

60

80

100

120

140

160

2003/04-2005/06

2004/05-2006/07

2005/06-2007/08

2006/07-2008/09

2007/08-2009/10

2008/09-2010/11

2009/10-2011/12

2010/11-2012/13


Alcohol-specific hospital admissions (person-based), 3-year rolling crude rate per

100,000, persons aged under 18, Aneurin Bevan UHB and Wales, financial years 2003/04-2012/13

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



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Liver transplant procedures The rate of liver transplant procedures in ABUHB is low at 0.8 per 100,000 (for the period 2004/05 – 2013/14), and is consistent with the all Wales average (Appendix 1: Figure 9). Endoscopic retrograde cholangiopancreatography (ERC) procedures

The rate of ERC procedures in ABUHB in 2013/14 is 45.5 per 100,000 which is among the highest in Wales, but not significantly higher than the all Wales average (Appendix 1: Figure 10). Paracetamol overdose hospital admissions

The ABUHB rate of hospital admissions due to paracetamol overdose (accidental or intentional poisoning) was 100.8 per 100,000 which is significantly lower than the all Wales average in 2013/14 (Appendix 1: Figure 11). Liver disease hospital admissions

The ABUHB rate of liver disease hospital admissions in 2013/14 was 91.8 per 100,000 which is consistent with the all Wales average (Appendix 1: Figure 12). Hepatitis B related end-stage liver disease/hepatocellular carcinoma hospital admissions

The ABUHB rate of hospital admissions due to Hepatitis B related end-stage liver disease / hepatocellular carcinoma is low at 0.8 per 100,000 (for the period 2004/05 – 2013/14) and is consistent with the all Wales average (Appendix 1: Figure 13). Hepatitis C related end-stage liver disease/hepatocellular carcinoma hospital admissions

The ABUHB rate of hospital admissions due to Hepatitis C related end-stage liver disease / hepatocellular carcinoma is 1.5 per 100,000 (for the period 2004/05 – 2013/14) and significantly lower than the all Wales average (Appendix 1: Figure 14). 3. Mortality Indicators

Pancreatic cancer mortality

The ABUHB mortality rate from pancreatic cancer (under 75 years of age) is 8.4 per 100,000, which is lower than the all Wales average (not significantly) and similar to other Health Boards in Wales (Appendix 1: Figure 15). Paracetamol poisoning mortality

The mortality rate from paracetamol poisoning is low across Wales, with the ABUHB rate being slightly lower than the Wales average at 0.5 per 100,000 in the period 2004-2013 (Appendix 1: Figure 16). Chronic liver disease (including cirrhosis) mortality

The mortality rate in ABUHB from chronic liver disease (all ages) is 14.6 per

100,000, which is consistent with the all Wales average (Appendix 1: Figure 17).


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Mortality is higher in males than females and this is also consistent with the

national picture.

The majority of chronic liver disease mortality occurs in those under 75 (Appendix

1: Figure 18).

All cause liver disease mortality, aged under 75 years

The mortality rate in ABUHB from chronic liver disease (under 75) is 22.3 per 100,000, which is slightly higher (not significant) than the all Wales average (Appendix 1: Figure 19). The mortality rate is higher in males than females and this is also consistent with the national picture. Liver cancer mortality, aged under 75 years

Liver cancer mortality rates are relatively small in the ABUHB area, at 5.1 per 100,000 in the period 2009-13. This is slightly higher than the all Wales average (which is 4 per 100,000) and this difference appears to be statistically significant (Appendix 1: Figure 20). Key points from the needs analysis

One quarter of the adult population in ABUHB are obese, and one quarter of

children aged 4 to 5 years are overweight or obese, with an upward trend in

obesity rates. It is anticipated that this will result in additional non-alcoholic

fatty liver disease that we are not yet seeing reflected in treatment services.

The health board has significantly more alcohol-specific hospital admissions

and admissions due to alcoholic liver disease in adults compared with the

Wales average, indicating that further work is needed on early identification

and treatment of alcohol misuse problems.

While use of treatment services and mortality rates from liver disease are

generally consistent with the all Wales average, they are still too high in

comparison to the rest of the UK and we must do more to improve the

detection and treatment of liver disease.

This needs analysis has highlighted that there is a data development agenda,

with better quality data needed to assist with planning and evaluating

services. There is a need for additional capacity to extract and analyse local

hospital-collected data which is of a good enough quality to use for audit and

evaluation purposes. In addition, there is a need for data on BBV testing and

treatment to ensure we are reaching all the groups at risk of developing viral

hepatitis.


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3. DEVELOPMENT OF ANEURIN BEVAN UNIVERSITY HEALTH BOARD LIVER DISEASE LOCAL DELIVERY PLAN

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 (BBV) Action Plan for Wales 2010-2015 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. The ABUHB Executive Lead for liver disease will need to report progress formally to their Boards against milestones in these delivery plans and publish these reports on their websites at least annually. Additional resource is required to deliver the Liver Disease Deliver Plan. Welsh Government have pledged £1 million to support the delivery of the plan, but it is yet unknown how this will be allocated. In relation to Health Board funding, a business case will be prepared for each scheme proposed in the plan. These scheme will highlight what additional benefit will be accrued from investment and these will be considered as part of the refresh of the IMTP for 2016/17 and the Clinical Futures programme. This plan is based on available data supplied by the PHW Observatory. The Public Health Team has also undertaken a review of local progress against Welsh Government’s BBV Hepatitis Action Plan to inform future action in this area. Partners from across the directorates within the health board, including Gastroenterology, Dietetics and local Alcohol Misuse Services have worked together to identify actions required to meet the priorities of the “Together for Health – Liver Disease Delivery Plan”, and these are detailed in the action plan below.


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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. We have summarised the ABUHB key priorities first, followed by the priorities as laid out in the national plan.

Aneurin Bevan University Health Board Key Priorities to 2020 1. Preventing Liver Disease: Develop an Integrated Alcohol Care Pathway

through the development of a secondary care based Alcohol Care Team (ACT) in

line with recent multi-agency reports and a NICE quality and efficiency guidance

which strongly endorse their implementation

2. Timely Detection: Build stronger links with primary care, supported by

guidelines, alerts and rapid access to specialist advice to ensure high quality of

liver care across the whole pathway

3. Fast and Effective Care: Planned expansion of the workforce providing care to

patients with liver disease which will ally with the Clinical Futures model with the

SCCC at its centre.

4. Living with Liver Disease: Support the introduction of ring-fenced liver “super”

clinics, attended by consultants, trainee doctors, specialist nurses, ANP’s and

dedicate dietetic support will be essential

5. Improving information: Set up a Gwent Liver Patient Panel and Support Group

to facilitate the co-productive approach to healthcare service redesign

6. Research: Dedicated data clerk time is essential and also supports delivery of

the whole plan. Dedicated data clerk time is essential and also supports delivery

of the whole plan, as well as research and evaluation

Priorities within the Welsh Government’s Liver Disease Delivery Plan (2015) 1) Preventing liver disease

The priorities are: 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


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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.

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.

6. Develop an approach to help de-stigmatise liver disease.

2) Timely detection of liver disease

The priorities are: 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.

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.

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.


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3) Fast and effective care

The priorities are: 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. Implementation group to support the development of regional networks to facilitate optimal service delivery and improvement including outreach services with transplant centres.

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

4) Living with liver disease

The priorities are: 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.


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5) Improving Information

The priorities are: 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.

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. 6) Targeting Research

The priorities are: 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.


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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. 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


Priority Actions Expected outcome Risks to delivery Timescales / Milestones

Lead

Preventing harm from alcohol misuse

Ensure appropriate effort is allocated to reducing the risk factors for liver disease and programmes reflect the potential contribution to reducing liver disease.

Respond to Welsh Government’s public consultation on the draft Public Health (Minimum Price for Alcohol) Bill

Clarification of the Health Board’s position on MUP as an effective way of targeting the heaviest drinkers and other groups at risk of alcohol related harm

None Dec 2015 Aneurin Bevan Gwent Public Health Team


Maximising the Health Board’s role as a Responsible Authority under the Licensing Act Review Statement of Licensing Policies for each Local Authority as appropriate. Introduce a data sharing agreement and protocol for alcohol misuse

Reduction in irresponsible sales of alcohol through effective use of licensing legislation e.g. cumulative impact areas

None Dec 2015 Dec 2015 Aug 2015

Aneurin Bevan Gwent Public Health Team Aneurin Bevan Gwent Public Health Team Aneurin Bevan Gwent Public Health Team


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Lead

statistics Put in place a protocol to improve the quality of alcohol misuse data collection in A&E

December 2016

A&E Department


Introduce and use the Gwent Substance Misuse Area Planning Board (APB) ‘Substance Misuse Primary Prevention Best Practice Guidance’ Conduct a refresh of the Gwent APB ‘Substance Misuse Primary Prevention Best Practice Guidance’ in conjunction with partner agencies and service users Identify and introduce evidence-based alcohol

Local priorities, plans and programmes reflect the available evidence in order to delay the onset of drinking among children, challenge the norms around drinking and reduce the harm to those who do drink.

None December 2015 December 2016 September 2016

Aneurin Bevan Gwent Public Health Team Aneurin Bevan Gwent Public Health Team Aneurin Bevan Gwent Public Health Team


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Lead

misuse prevention programmes in schools. Develop and design an appropriate intervention to address alcohol misuse in the 50+ age group

March 2016

Aneurin Bevan Gwent Public Health Team

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

Development of an Alcohol Care Team as part of an integrated alcohol pathway Advocate for the inclusion of alcohol misuse as an Neighbourhood Care Network (NCN) priority for 2016/17

Improved quality of care for patients admitted with alcohol misuse problems and cost savings relating to length of stay and service usage Use of appropriate screening tools to identify patients with alcohol use disorders for brief intervention and appropriate referral to the Gwent Drug & Alcohol Service.

Subject to approval of business case Funding required for GPs with Special Interest (GPwSI) and to commission enhanced services

April 2016 – 3 year rolling programme September 2016

Consultant Gastroenterologist Primary Care and Networks


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Lead

Implement the Living Well, Living Longer programme in deprived areas Explore the potential for extending Nalemefene prescribing for harmful drinking and mildly dependant drinkers

As above. Reduce alcohol consumption in people with alcohol dependence

Capacity within primary care to provide on-going psychological support

Programme implementation ongoing 2015 - 2018 September 2016

Primary Care and Networks Primary Care and Networks

Preventing the transmission and improving the diagnosis and treatment of Blood Borne Viruses (BBVs)

Take forward the legacy of the Blood Borne Viral Hepatitis Action Plan in all relevant settings and continue the effort to eradicate viral hepatitis

Perform review of progress against BBV action plan in ABUHB

Clarity around the actions which need to be taken forward over the next 3 years

None September 2015

Aneurin Bevan Gwent Public Health Team

Take forward the legacy of the Blood Borne Viral Hepatitis

Establish baseline data to be able to monitor and evaluate future

Ability to monitor and audit actions necessary to prevent the

Dependant on continued funding for Data Clerk

January 2016 Aneurin Bevan Gwent Public Health Team


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Lead

Action Plan in all relevant settings and continue the effort to eradicate viral hepatitis

actions to prevent the transmission and improve the diagnosis and treatment of BBVs in all high risk groups

transmission and improve the diagnosis and treatment of BBVs in all high risk groups

Take forward the legacy of the Blood Borne Virus Hepatitis Action Plan in all relevant settings and continue the effort to eradicate viral hepatitis

Ensure effective supply of Needle Exchange services in the ABUHB area

Prevention of BBV spread in the people who inject drugs (PWID) community

Ability to meet the ongoing costs of Needle Exchange services

Stepped upgrade of service provision each year between 2015 – 2020 to establish gold standard provision

APB

Take forward the legacy of the Blood Borne Virus Hepatitis Action Plan in all relevant settings and continue the effort to eradicate viral hepatitis

Design and deliver a targeted community testing for Hep B and Hep C in Newport for those born in countries with high prevalence Promote and increase uptake of a targeted community testing for Hep B and Hep C in

Raised awareness and increase in targeted community testing for Hep B and Hep C Raised awareness and increase in targeted community testing for Hep B and Hep C

March 2016 In place and ongoing

ABGPHT/ Hepatology APB Secondary Prevention Group


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Lead

PWID Conduct a baseline audit of targeted community testing for Hep B and Hep C in HMP Usk and Prescoed to inform future action to ensure it is a routine part of screening Conduct an audit of targeted Hep B testing of pregnant women in high risk populations and post-exposure Hep B immunisation for babies born to infected mothers

Testing for Hep B and Hep C, and immunisation for Hep B to become routine part of screening medicals in HMP Usk and Prescoed Ensure all at risk women and babies are offered HBV testing and vaccination as appropriate

March 2016 March 2016

Primary Care & Networks / Public Health Wales / BBV Lead Maternity Services

Preventing child obesity and improving access to weight management services

Ensure appropriate effort is allocated to reducing the risk factors for liver disease and

Develop a multi-agency Child Obesity Strategy for Gwent based on the system causes of obesity

Tackle the causes of overweight and obesity in children

2014/15

ABUHB Local Authorities LSBs/PSBs


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Lead

programmes reflect the potential contribution to reducing liver disease.

A Gwent wide Childhood Obesity Action Plan developed and agreed by all key partners

2015/16

Agree weight management and obesity as a priority for NCN plans for 2015/16

Increase the identification of obese patients within primary care and appropriate referral to Adult Weight Management Service

September 2015

Primary Care and Networks Division

Present annual report for Adult Weight Management Service (AWMS) to Board Present business case for extension of the service

Extending AWMS to meet demand

Resources/ capacity available to meet demand

Professional Manager - Adult Weight Management Service

Introduce Child Weight Management Service

Integrated Business case developed

Approval of business case

Possible implementation by April 2016

Professional Manager - Adult Weight Management Service


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Timely detection of liver disease


Lead

Improve provision of assessment and testing of those at highest risk of developing liver disease.

Contribute to national pathways of care and referral guidelines

Standardisation of care in line with evidence based principles

None 2016/17 Consultant Gastroenterologist

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

Develop a simple referral pathway for abnormal liver function test pending national guideline publication Agree NCN lead to support introduction of new guidance for GP clusters on risk management and referral

Improvements in risk management, detection and referral

None April 2016 April 2016

Consultant Gastroenterologist Consultant Gastroenterologist /NCN lead

Undertake a cost assessment of improving the effectiveness of the

Work with clinical biochemistry to introduce AST/ALT ratio risk assessment pilot

Improvements in early detection in advanced disease and greater efficiency in testing

Capacity with Pathology

April 2016

National work taking into account the soon to be reported Scottish


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routine use of risk assessment tools (such as routine provision of AST/ALT ratio) to identify those at greatest risk of significant liver disease.

resulting in reduced cost, in line prudent healthcare principles.

experience

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

Refine the pathway for low risk patients in light of national guidance and local evidence

Improved system of appropriate ongoing monitoring and investigation to detect the possibility of disease progression in patients initially identified as low risk

None December 2017

National Implementation Group

Measure performance against key standards in the

Measure performance locally as part of the national audit of the

Ability to benchmark against national standards to ensure

None 2017/18 Consultant Gastroenterologist /NCN lead


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

pathway

appropriate outcomes are being met.

Fast and effective care


Lead

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.

Implement the Clinical Future model to centralise services within the Specialist and Critical Care Centre (SCCC).

Increase in Consultant Gastroeterologists with specialist interest in Hepatology to support 7 day working and SCCC model.

Costs Challenges in recruitment

Need is immediate though implementation will be determined by ability to recruit which likely will take 2-3 years

Clinical Director Gastro/Directorate manager/Divisional Director/Clinical Futures Team

Health boards review liver disease

Continue to introduce the BSG

Improvements in the quality of care provided

None January 2016 Consultant Gastroenterologist


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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.

decompensated care bundle within MAU and work with Informatics to include on Clinical Work Station (CWS)

within the first 24 hours of admission.

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.

Update existing ABUHB guidance and publish on intranet web pages to align with national standards Contribute to the development of national standards through the Welsh Association for Gastroenterology and Endoscopy (WAGE)

Ability to ensure that guidance reflects current best practice

None August 2016 2016/17

Consultant Gastroenterologist


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Living with liver disease


Lead

Facilitate the strengthening of the co-productive approach to designing services and treatment plans. Engage community support groups to help patients manage their condition in the community.

Establish a liver disease patient panel with support from the British Liver Trust

Patient voice in service design and delivery

None September 2016


Consider the feasibility of developing one-stop-shop cirrhosis clinics where patients can have their disease monitored and surveillance ultrasound scans undertaken as appropriate.

Develop a multi-disciplinary liver clinic to include consultants, doctors in training, specialist nurses and dieticians in training.

Improvements in the quality of care provided for complex patients with appropriate monitoring and advice given and improved concordance with treatment plans and dietary advice.

Subject to greater availability of dedicated dietetic sessions. Ability to recruit to vacant post following retiring consultant.

Consultant Gastroenterologist Clinical Director Gastroenterology Directorate Manager


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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.

Produce a business case for dedicated dietetic support. Recruitment of dietician as part of the multi-disciplinary team

Appropriate care for decompensated cirrhosis patients.

Subject to resources being made available

Dec 2015 Clinical Director Gastroenterology

Examine opportunities to encourage and support better primary care management of those diagnosed with liver disease including improved uptake of appropriate vaccinations.

Advocate for inclusion of liver disease management and alcohol misuse as a priority within NCN plans for 2016/17, particularly within areas of deprivation

Better access to and consistency of information about the management of liver disease across the primary/ secondary care interface.

Ability to get Liver Disease onto NCN plans

2016/17 Consultant Gastroenterologist in conjunction with NCN lead for Gastroenterology and Hepatology and NCN lead for substance misuse

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

Formalise the existing links and information to guide appropriate referral to palliative care

Improved symptom management for patients living with liver disease

None – maximising the use of existing resources

Immediately and for review in 2016/17



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Improving information


Lead

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.

Work with NWIS to review existing clinical system and improvement of clinical management systems through representation on the Implementation Board

Standardised care to limit variations in outcomes

Engagement of NWIS

2018-2020 National Implementation Group/ NWIS

Develop a local care plan for people with advanced liver disease to streamline the care they receive.

Improved patient understand of the management of advanced liver disease.

Time constraints on consultant staff

2016 Consultant Gastroenterologist

Develop national management guidelines facilitating the assessment of individuals with abnormal LFTs; these should include guidelines for the management of

See above on early detection of disease.

Standardise care, and improve information resources

2017 WAGE


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common complications of liver disease and indicators for referral.

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.

Continue to organise annual CPD event for nurses and allied health professionals Continue to disseminate the liver disease handbook for nurses. Work with University of South Wales to develop a Masters degree module on liver disease

Annual Ongoing 2017/18


To develop the Develop a proposal to Clear and timely Subject to funding March 2016 Consultant


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delivery plan set of measures in order to understand the current situation and the size of the issue

expand existing data clerk capacity to extract, collate and present hospital activity data and links to Informatics for analysis

understanding of capacity gaps, support for audit and evaluation to advance service developments.

Gastroenterologist with support from Data Clerk and Informatics Department

Targeting research


Lead

Undertake a gap analysis and identify key pieces of research needed and work with NISCHR to develop opportunities to address such gaps.

Explore the utilisation of data linkage to better understand liver disease and its risk factors.

Establish a database for liver disease to facilitate

National work needed to steer this. However local work is progressing in researching the issue of alcohol misuse and the prevalence, aetiology and outcomes of liver disease in the over 65’s Review current data capture and how this could be improved As described. ABUHB however already has a

Better understand the behaviour of liver disease in the elderly More sophisticated and specific data capture and linkage to provide incidence, outcome and develop quality metrics As described

Clinician time as there are no joint academic/clinical appointments within the department NWIS support Data support availability

2017-2018 2017-2018 2017

National Implementation Group on national issues and Consultant Gastroenterologist for all others National Implementation Group/NWIS National Implementation


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all Wales research and funding; including mechanisms for the application of research findings.

Explore undertaking research into methods for improving surveillance strategies in hepatocellular carcinoma.

Explore undertaking research into the relationship between lifestyle choices and liver disease and how these can be tackled.

Assess the impact of the “Have a Word” brief intervention training programme.

nascent liver disease database comprising 1,600 individuals that is in the process of being updated and refined This will require national work As described Measure the outcome of the training programme

Improved understanding of which patient benefits most form HCC surveillance As described Ensure return on investment and to refine the programme if necessary

Will require a large funding grant Funding Needs to become a NISCHR priority area Funding

2020+ Up to 2020 2018

Group/NWIS NISCHR, National Implementation Group PHW/NISCHR PHW


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Increase the number of joint academic appointments between health boards and local universities.

As described

Improve research output to improve patient care

Funding of research sessions for clinicans with the skills/interest

2018

National Implementation Group, Health Board to explore links with partner University


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Figure 2: Hospital admissions due to non-alcoholic fatty liver disease, 2009/10 – 2013/14

Appendix 1: Additional charts relating to the overview of local health need related to liver disease prevention and service provision

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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Figure 9: Liver transplant procedures, 2004/05 – 2013/14

Figure 10: Endoscopic retrograde cholangiopancreatography (ERC) procedures, 2013/14

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)


26.5 33.2 24.1 51.2 75.1 54.1 45.5

Betsi

Cadwaladr UHB

Powys THB Hywel Dda

HB

ABM UHB Cardiff &

Vale UHB

Cwm Taf HB Aneurin

Bevan HB

Endoscopic retrograde cholangiopancreatography (ERC) procedures*, European

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


Wales = 43.2

*OPCS code J43 (any mention)



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Figure 11: Paracetamol overdose hospital admissions, 2013/14

Figure 12: Liver disease hospital admissions, 2013/14

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)


94.0 62.0 84.4 87.5 89.6 118.9 91.8

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB


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



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Figure 13: Hepatitis B related end-stage liver disease/hepatocellular carcinoma hospital admissions, 2004/05 – 2013/14

Figure 14: Hepatitis C related end-stage liver disease/hepatocellular carcinoma hospital admissions, 2004/05 – 2013/14

0.8 0.7 1.1 0.6 0.8

Betsi

Cadwaladr UHB

Powys tHB** Hywel Dda

UHB


UHB

Cwm Taf

UHB**

Aneurin

Bevan UHB

* ICD-10 codes B16, B180-B181 (principal diagnosis)** Rates have been suppressed due to the low number of events

Hospital admissions due to Hepatitis B related end-stage liver disease/hepatocellular

carcinoma*, European age-standardised rate (EASR) per 100,000, all persons all ages, Wales health boards, 2004/05-2013/14Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)


Wales = 0.8


4.2 2.7 3.4 5.9 1.3 1.3 1.5

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff &

Vale UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Hospital admissions due to Hepatitis C related end-stage liver disease/hepatocellular

carcinoma*, European age-standardised rate (EASR) per 100,000, all persons all ages, Wales health boards, 2004/05-2013/14Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)


Wales = 3.1

*ICD-10 codes B171 & B182 (principal diagnosis)



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Figure 15: Pancreatic cancer mortality, 2011-13

Figure 16: Paracetamol poisoning mortality, 2004-13

8.2 9.0 8.1 9.2 9.7 7.7 8.4

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff &

Vale UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Pancreatic cancer mortality*, European age-standardised rate (EASR) per 100,000, all

persons aged under 75, Wales health boards, 2011-13Produced by Public Health Wales Observatory using PHM & MYE (ONS)


Wales = 8.6

*ICD-10 code C25 (underlying cause)

0.7 0.0 0.8 0.8 0.8 0.5

Betsi

Cadwaladr UHB

Powys tHB** Hywel Dda

UHB**


UHB

Cwm Taf UHB Aneurin

Bevan UHB

Paracetamol overdose mortality*, European age-standardised rate (EASR) per 100,000,

all persons all ages, Wales health boards, 2004-13Produced by Public Health Wales Observatory using PHM & MYE (ONS)


Wales = 0.6

*Paracetamol overdose mortality has been identified where a record contains any mention of ICD-10 codes T39.1 and either X40 (accidental poisoning) or X60 (intentional poisoning) in any cause position**Rates have been suppressed due to the low number of events




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Figure 17: Mortality from chronic liver disease, including cirrhosis, all ages, 2011-13

Figure 18: Mortality from chronic liver disease, including cirrhosis, by age group, 2004-06 to 2011-13

0

20

40

60

80

100

Betsi Cadwaladr UHB

Mortality from chronic liver disease including cirrhosis*, annual average deaths by age group, all

persons aged 20 and over, Wales health boards, 2004-06 to 2011-13

0

20

40

60

80

100

Powys tHB Hywel Dda UHB

Cardiff & Vale UHB

0

20

40

60

80

100ABM UHB

An

nu

al average d

eath

s

Produced by Public Health Wales Observatory, using PHM (ONS)

0

20

40

60

80

100

2004-0

6

2005-0

7

2006-0

8

2007-0

9

2008-1

0

2009-1

1

2010-1

2

2011-1

3

Cwm Taf UHB

2004-0

6

2005-0

7

2006-0

8

2007-0

9

2008-1

0

2009-1

1

2010-1

2

2011-1

3

Aneurin Bevan UHB

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

0

20

40

60

80

100

120

20-74 75+


14.5 9.6 11.4 15.6 14.8 16.5 14.6

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

rate (EASR) per 100,000, males, females and persons all ages, Wales health boards, 2011-13Produced by Public Health Wales Observatory using PHM & MYE (ONS)


Wales = 14.3

Persons

18.0 10.8 15.3 20.3 19.3 20.6 18.2

Wales = 18.1

Males

11.0 8.6 8.1 11.4 10.5 12.6 11.3

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB


UHB

Cwm Taf UHB Aneurin

Bevan UHB

Wales = 10.7

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

Females



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Figure 19: Mortality from all cause liver disease, under 75 years, 2011-13

Figure 20: Liver cancer mortality, 2009-13

3.1 3.8 2.8 3.9 5.1 5.0 5.1

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff &

Vale UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Mortality from liver cancer*, European age-standardised rate (EASR) per 100,000, all

persons aged under 75, Wales health boards, 2009-13


Wales = 4.0

*ICD-10 code C22 (underlying cause)

20.2 14.1 15.3 21.8 20.4 25.2 22.3

Mortality from all liver disease*, European age-standardised rate (EASR) per 100,000,

males, females and persons aged under 75, Wales health boards, 2011-13Produced by Public Health Wales Observatory using PHM & MYE (ONS)


Wales = 20.4

Persons

24.7 17.6 18.2 29.2 27.7 31.8 29.0

Wales = 26.1

Males

15.8 10.8 12.5 14.9 13.6 18.9 15.9

Betsi

Cadwaladr UHB

Powys tHB Hywel Dda

UHB

ABM UHB Cardiff &

Vale UHB

Cwm Taf

UHB

Aneurin

Bevan UHB

Wales = 15.0

Females

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



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