Need and Capacity for Cardiac Rehabilitation
Authors: Nigel Monaghan, Deputy Director of Health and Social Care Quality
Date: 15/10/08 / Version: 1a
Status: Final
Intended Audience: Cardiac Networks, LHB’s, Trusts
Purpose and Summary of Document:
This paper summarises advice from the NPHS on translation of information on need into capacity in line with NICE Commissioning Guidance on Cardiac Rehabilitation
Publication/Distribution:
· Cardiac Networks
· Publication in NPHS HSCQ Document Database
· Link from NPHS e-Bulletin
· Link from Stakeholder e-Newsletter
1 Background
On 29th February a letter was sent from the Welsh Assembly to LHB Chief Executives informing them of the need for local “cost and clinically effective cardiac rehabilitation services” as part of “an integral part of the package of care for people at risk of or who have cardiac disease”. The letter went on to request “each LHB in each of the 3 regions, working together through the Cardiac Network, must assess current cardiac rehabilitation provision against the requirements of the NSF Standards and submit a Network level action plan for the delivery of the NSF Standards to the relevant Regional Office by 31 December 2008.”
In addition to supporting the action plans the letter covered spending plans associated with existing projects funded by the Inequalities in Health Fund or the Big Lottery Fund, and the need for joint working with Stop Smoking Wales and the National Exercise Referral Scheme. £2 million of the 2008-09 LHB discretionary allocation was ring-fenced for these services matching existing Inequalities in Health and Big Lottery funding which had come to an end .
The letter indicated that a data collection exercise will be undertaken to ascertain the baseline investment in services, and any shortfall in the ring-fenced sum will be corrected during 2008-09.
A WAG project is seeking to develop exercise referral schemes to accept people participating in phase 4 cardiac rehabilitation. Thus the local cardiac rehabilitation plans need to incorporate phases 1 to 4 allowing for this anticipated change.
In support of the Cardiac Networks in co-ordinating these tasks the NPHS have been asked to provide advice related to need and demand for these services.
2 Evidence Base for Cardiac Rehabilitation
2.1 Policy Context
Cardiac rehabilitation is being promoted because it has the potential to prevent premature deaths. Cardiac rehabilitation whilst proven to be effective and cost-effective is not currently provided across the whole of Wales to a consistent minimum standard.
The Cardiac Network Co-ordinating Group submission to the Welsh Assembly Government proposing updates to the Wales National Service Framework for Coronary Health Disease and Arrhythmias recognises the need to be more flexible in delivery of cardiac rehabilitation to reflect the needs of individual patients.1 The classification now used by NICE for cardiac rehabilitation is phase 1 – inpatient, phase 2 – early post-discharge rehabilitation, phase 3 – definitive rehabilitation service, phase 4 – long term maintenance.2
Experience in Wales and elsewhere shows that even where it is offered cardiac rehabilitation is not always utilised for a range of reasons:
Poor referral, take-up and attendance have been identified as problems facing cardiac rehabilitation services in the UK. There are several reasons for the lower than expected levels of participation. These include a lack of engagement (people not invited to attend cardiac rehabilitation), low levels of referral, scarcity of service provision and poor take-up due to practical reasons (for example, location and time of the session).2
Across the UK cardiac rehabilitation is currently delivered in a combination of home, community and hospital settings. As a general rule in Wales and in line with Designed for Life3 the expectation is that services will be provided as locally as possible consistent with provision of safe and effective services. There is no reason to assume that provision in a non-hospital setting should affect the outcomes of cardiac rehabilitation for suitable patients although there is some evidence to suggest that patients prefer to attend local non-hospital based sessions and that provision of such sessions increases uptake significantly.4 A reported reason for drop-off in attendance for hospital based cardiac rehabilitation is that patients dislike the hospital setting and find access difficult. Applying this to cardiac rehabilitation over the longer term with increasing experience and confidence we would expect to see a shift of rehabilitation from the hospital except for those patients where it is assessed that risks associated with the rehabilitation are large enough to necessitate this being provided in a hospital. Thus a shift may be indicated where there is limited hospital based rehabilitation, but some hospital based rehabilitation will still be required for high risk individuals. Whatever setting the rehabilitation is undertaken in it is important to review participation rates, completion rates, and user satisfaction among those who complete and do not complete rehabilitation alongside other outcome data.
Due to the difficulties associated with conducting randomised controlled trials of different models of care across most of healthcare there is only limited good quality scientific evidence to support decisions on a particular model of care over another. This is also true for cardiac rehabilitation. Conversely cardiac rehabilitation provided in hospital, community and home settings have all proven effective, for example home rehabilitation has been shown to provide similar benefits to hospital based rehabilitation and some patients prefer it.2 The key issues are to ensure all patients meeting guidance on need are offered cardiac rehabilitation, and to ensure uptake that they are offered a range of options which have the potential to meet their needs and circumstances. Given experiences across the UK these should arguably include hospital, community and home based options.
2.2 NICE Commissioning Guidance on Cardiac Rehabilitation
On March 20th 2008 NICE published a commissioning guide on cardiac rehabilitation (CR). The commissioning guide should be read in conjunction with the clinical guideline published in May 2007 MI: secondary prevention. Secondary prevention in primary and secondary care for patients following a myocardial infarction.
The prime aim of a cardiac rehabilitation programme is encouraging and supporting individuals at risk of further events associated with cardiac disease to achieve and maintain optimal physical and psychosocial health. This is tailored to the needs of each patient based on a comprehensive assessment of their cardiac risks. The set of services encompass a multidisciplinary team of health professionals employed by different bodies but acting in partnership. The NICE Commissioning Guide gives details of how to develop and commission a high quality comprehensive cardiac rehabilitation group and emphasises the need to provide services tailored to the needs of the patient.
There are 4 sections to the commissioning guide:
· Commissioning a cardiac rehabilitation service
· Specifying a cardiac rehabilitation service
· Ensuring Corporate and Quality Assurance
· Determining local service levels for a cardiac rehabilitation service
2.2.1 POTENTIAL BENEFITS OF CARDIAC REHABILITATION
The commissioning guide lists a number of potential impacts on mortality and morbidity. These include greater survival for people with coronary heart disease who participate in comprehensive cardiac rehabilitation. There is evidence that cardiac rehabilitation reduces the risk of total and cardiac related mortality and reduces the occurrence of non-fatal MI .
Evidence also suggests that cardiac rehabilitation results in improving people’s ability to work, their physical capacity and perceived quality of life In addition it indicates improved exercise tolerance and quality of life for people with mild to moderate heart failure.
Participation in comprehensive cardiac rehabilitation can enable people to become active self managers of their condition, and this can assist in reducing unplanned hospital admissions. It also reduces the need for subsequent revascularisation for those undergoing vascular procedures.
Comprehensive rehabilitation also offers an opportunity to reduce inequalities associated with heart disease. Overall providing rehabilitation offers better value for money than not providing it.
CNS are able to organise prompt and timely admission to hospital when patients symptoms deteriorate in order to prevent adverse effects.
COMMISSIONING A CARDIAC REHABILITATION SERVICE
The NICE Commissioning Guidance on Cardiac Rehabilitation indicates that cardiac rehabilitation should not be regarded as an isolated form or stage of therapy but be integrated within secondary prevention services. Having said that, cardiac rehabilitation services are no longer exclusively hospital based. Emphasis is placed on helping patients become active self-managers of their condition and this can involve hospital, home and community based cardiac rehabilitation programmes, all of which are effective.
NICE estimate that the cost of cardiac rehabilitation varies enormously throughout the UK, from £17 to £2186 per patient, despite it being highly cost effective at their estimate of the mean cost of £550 per patient.
Based on their analysis of the evidence base NICE have indicated that those with the greatest potential to benefit from cardiac rehabilitation should be the priority until such time as there is capacity to rehabilitate all those who could benefit. NICE suggest that once trusts have an effective system for identifying, treating and following up people who have survived an MI or who have undergone coronary revascularisation (coronary artery bypass graft and percutaneous coronary intervention) they should consider extending their rehabilitation services to people admitted to hospital with stable angina, heart failure, those having cardiac transplant and those receiving implantable cardiac defibrillators. NICE Commissioning Guidance on Cardiac Rehabilitation suggests that key clinical issues in providing an effective comprehensive cardiac rehabilitation service are:
· actively identifying all people potentially eligible for cardiac rehabilitation and encouraging them to take part in cardiac rehabilitation prior to hospital discharge
· assessing an individual’s risk and need for cardiac rehabilitation and developing individualised plans to meet those needs in line with NICE clinical guideline CG48 on MI: secondary prevention and the British Association for Cardiac Rehabilitation document ‘Standards and core components for cardiac rehabilitation’. The Quality requirements within standard 6 of the NSF detail these clinical components further.
· providing a quality assured service.
NICE guidance does not make specific recommendations regarding patients with chronic CHD, or who had a past event.
2.2.2 SPECIFYING A CARDIAC REHABILITATION SERVICE
The 29th February 2008 letter from WAG indicated concerns that access to service in Wales is “patchy”. The NICE Guidance on Cardiac Rehabilitation indicates that where cardiac rehabilitation services have been adequately resourced and where they have systematically identified people and adopted a structured approach to their work, the numbers of people treated have increased.
Thus for Wales it is proposed that the key service components of a cardiac rehabilitation service are:
· systematically identifying and actively engaging people potentially eligible for cardiac rehabilitation
· developing a high-quality multidisciplinary comprehensive cardiac rehabilitation service in line with British Association for Cardiac Rehabilitation guidance.5
Structures and Processes
Local health boards, local authorities, NHS Trusts, and the voluntary sector should agree the range and availability of services that can be drawn on for cardiac rehabilitation. For example, local authority leisure centres, church halls or other easily accessible public venues may be appropriate for cardiac rehabilitation sessions, and appropriately trained local authority staff can play a useful role in supervising physical activity and supporting exercise referral schemes. Note that in the context of suitably trained staff there are specified skills and competencies for people supervising patients undertaking phase 3 and phase 4 cardiac rehabilitation. Hospital staff and facilities will be required for those patients assessed as high risk.
There is no single model of delivery of cardiac rehabilitation which can be recommended from the evidence base and there is a need for many options to suit the circumstances of the patient. Following a comprehensive assessment patients should have access to services within the hospital, community and home. this would be dependant on their risk assessment, personal choice and access. From the viewpoint of patients hospital, community and home are all possible settings). From the viewpoint of participation and maximising the health gained from cardiac rehabilitation all of these options should ideally be offered across Wales. From the viewpoint of the taxpayer, the service should be effective and cost-effective. The vehicle options for delivering all of these include:
· A highly detailed service specification covering all details of the service supported by details in individual patient records
· A less detailed service specification indicating client groups, settings, hours of operation and outcomes supported by detailed protocols and individual patient records (which may or may not include care pathways).
The Cardiac Networks are better placed than the NPHS to decide how they wish to provide advice on service specifications and protocols.
Given that there are various models of delivery in operation in Wales, that these reflect to some degree local circumstances and that there is no good evidence to support one method of delivery over another the option of a less detailed service specification which operates in line with locally appropriate and more detailed local protocols would seem to be the more flexible approach.
Whichever combination of service specification/protocol/care pathway option is chosen it needs to cover:
· the target groups currently served
· the expected number of patients based on discharge data for the target groups (this should take into account how quickly any changes in service provision are likely to take place)
· ease of access, service settings and hours of operation (commissioners should engage with service users and other relevant individuals and organisations locally and consider need for home, community and hospital based elements)
· outcomes expected in terms of targets for clients offered cardiac rehabilitation, waiting times and number of clients waiting for access to cardiac rehabilitation, targets for clients choosing to participate in cardiac rehabilitation, targets for clients completing rehabilitation by phase, clinical outcomes expected and service user satisfaction with services; these will for the basis of service monitoring criteria
· information, quality assurance and audit requirements, including IT support and infrastructure for all settings and phases
· the required competencies of and training for, staff responsible for providing the service for all settings and phases