NHS                                       NHS ImprovementCANCERDIAGNOSTICS              Heart Improvement              Car...
Cardiac RehabilitationCardiac rehabilitation (CR) is a national priority project of NHS Improvementfocusing on increasing ...
Cardiac Rehabilitation - National Priority Projects    3ContentsForeword                                                  ...
4       Cardiac Rehabilitation - National Priority Projects        Foreword                                      During th...
Cardiac Rehabilitation - National Priority Projects          5Foreword                             The cardiovascular netw...
6       Cardiac Rehabilitation - National Priority Projects        Introduction                                     The Na...
Cardiac Rehabilitation - National Priority Projects    7Key LearningOutlined below are some of the key learningidentified ...
8       Cardiac Rehabilitation - National Priority Projects        Quality, Innovation, Productivity        and Prevention...
Cardiac Rehabilitation - National Priority Projects           9                                              Project Summa...
10      Cardiac Rehabilitation - National Priority Projects        Commissioning an equitable service across the county   ...
Cardiac Rehabilitation - National Priority Projects         11What we did                                             The ...
12      Cardiac Rehabilitation - National Priority Projects        The biggest issue/challenge                            ...
NHS                                                                            NHS ImprovementCANCERDIAGNOSTICSHEARTLUNG  ...
Cardiac Rehabilitation - National Priority Projects        13A sector wide approach to cardiacrehabilitation in South West...
14      Cardiac Rehabilitation - National Priority Projects        Research findings and local patient feedback          M...
Cardiac Rehabilitation - National Priority Projects        15The biggest issue/challenge                            Work t...
16      Cardiac Rehabilitation - National Priority Projects        each borough, with a recommendation that              K...
Cardiac Rehabilitation - National Priority Projects      17Information transfer                                  Work to a...
18      Cardiac Rehabilitation - National Priority Projects        Rehabilitation triage assessment        North Lincolnsh...
Cardiac Rehabilitation - National Priority Projects       19The expected outcome measures are:                     Demand ...
20      Cardiac Rehabilitation - National Priority Projects        The biggest issue/challenge        Challenges remain re...
Cardiac Rehabilitation - National Priority Projects      21Each programme has an identified programme             partners...
22      Cardiac Rehabilitation - National Priority Projects        Planning cardiac rehabilitation commissioning        Do...
Cardiac Rehabilitation - National Priority Projects       23The key aims of the project – using a phased          4. Links...
24      Cardiac Rehabilitation - National Priority Projects        The difficulty comes when you have set        goals tha...
Cardiac Rehabilitation - National Priority Projects   25• Introduce the Heart Manual as an additional  method of delivery ...
26      Cardiac Rehabilitation - National Priority Projects        Modernising a cardiac rehabilitation service        Nor...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
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Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...
Cardiac rehabilitation (CR) is a national priority project of NHS Improvement focusing on increasing the access to, equity of provision and uptake of CR services for heart attack, angioplasty and CABG patients. The project summaries include issues to be addressed, baseline position, actions taken, key learning, QIPP outcomes and results to date from the 11 projects participating in this work.
(Published October 2009).

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Cardiac Rehabilitation - National Priority Projects: Lessons and learning one year on...

  1. 1. NHS NHS ImprovementCANCERDIAGNOSTICS Heart Improvement Cardiac Rehabilitation -HEART National Priority Projects Lessons and learning one year on...LUNG October 2009STROKE
  2. 2. Cardiac RehabilitationCardiac rehabilitation (CR) is a national priority project of NHS Improvementfocusing on increasing the access to, equity of provision and uptake of CRservices for heart attack, angioplasty and CABG patients.The time scale for the projects varies, with some projects still in the initialstages. Key learning from the project is available in brief in the introductionto this document and in more detail in each of the project summaries.Project summariesProject summaries include issues to be addressed, baseline position, actionstaken, key learning and results to date from the 11 projects participating inthis work.Contact details are included to provide additional information with regularupdates available on the website at www.improvement.nhs.uk/heart/rehab
  3. 3. Cardiac Rehabilitation - National Priority Projects 3ContentsForeword 4Introduction 6Key Learning 7Quality, Innovation, Productivity and Prevention 8Project Summaries 9Commissioning an equitable service across the county 10Derbyshire County PCTA sector wide approach to cardiac rehabilitation in South West London 13South West London Cardiac and Stroke NetworkRehabilitation triage assessment 18North Lincolnshire and Goole NHS TrustPlanning cardiac rehabilitation commissioning 22Dorset Cardiac and Stroke NetworkModernising a cardiac rehabilitation service 26NHS North of Tyne, North of England Cardiovascular NetworkA redesigned service for North Staffordshire 30Shropshire and Staffordshire Heart and Stroke NetworkImproving access for Surrey patients 33Surrey Heart and Stroke NetworkAudit on the uptake of phase three cardiac rehabilitation 36Black Country Cardiovascular NetworkReferral to cardiac rehabilitation for PPCI patients 39North West London Cardiac and Stroke NetworkVocational rehabilitation project 41North West London Cardiac and Stroke NetworkCardiac rehabilitation across the Peninsula 44Peninsula Heart and Stroke NetworkProject Team 47 www.improvement.nhs.uk/heart
  4. 4. 4 Cardiac Rehabilitation - National Priority Projects Foreword During this time of imminent financial constraint and commissioning pressures the national priority projects for cardiac rehabilitation (CR) have created a real sense of optimism within the clinical teams and have led to significant positive change which will become evident over the coming years. NHS Improvement - Heart has taken positive action towards ensuring that lessons learnt in one work stream become the building blocks for other teams. This critical mass approach is key to achieving the greatest impact in the shortest possible time which, for CR, is important because the challenge ahead is huge! Recent National Audit of Cardiac Rehabilitation (NACR) figures show that uptake remains low (mean 38%) and that average trends in uptake did not change in 2007-2008. The NACR report and the network survey of CR highlighted that referral to rehabilitation is one of the biggest hurdles to ensuring higher uptake. There is clearly plenty of work to do but I believe the CR priority projects have the right focus to tackle the problem, for example service redesign, innovations in commissioning and leadership development, which we all know are important issues and challenges facing practitioners and service providers. The national priority projects for CR are the test bed for tariff debate and collectively we are making a real contribution to shaping the future national tariffs for CR. One of the lessons, so far, is that tariff doesn’t bring new money but what is does is give commissioners and providers a clear framework for what CR costs. What we have learnt, through the CR projects, is that service specification is the key to commissioning best practice CR. NHS Improvement - Heart is primed to produce meaningful support structures to help commissioners and providers achieve this is their own localities. It is less than one year since the CR national projects started yet we already have some clear success stories from individual projects and we see similar promise as the present projects roll out. The CR projects are fully inclusive and thrive on close liaison with local commissioners, cardiologists, CR practitioners and cardiac networks all of whom are committed to innovations aimed at enhancing referral to CR and reducing inequalities in access over the next 12 months. The CR project team are tasked with making sure that the best possible outcomes prevail and that success is shared with others. My role as national clinical lead has been made possible and strengthened by close partnership with NHS Improvement - Heart and particularly Linda Binder and Dr Jane Flint both of whom have the skills and motivation to take the battle to where it counts. We look forward to even greater success over the next few years as we enable one of the most strongly supported clinical interventions, that brings substantial benefits to patients, to become a reality for those that require it. Professor Patrick Doherty National Clinical Lead for Cardiac Rehabilitation to NHS Improvementwww.improvement.nhs.uk/heart
  5. 5. Cardiac Rehabilitation - National Priority Projects 5Foreword The cardiovascular networks always promised to be effective health communities, across which sharing good practice and ultimately redesigning ideal care pathways for patients, including cardiac rehabilitation could be made. Commissioning against commitment to key defined outcomes is important. Although only a minority of networks has so far worked with the national team on priority projects, these networks already show an appreciation of both achievements of programmes, and most importantly, the challenges faced across their respective territories.Our first completed audit cycle of the network survey of cardiac rehabilitation development hashighlighted the minority view as yet of robust commissioning, but increasing opportunity with roll-outof Primary PCI for STEMI to include cardiac rehabilitation within the business case. From North ofTyne to Pan London down to Peninsula there has been real progress, through their projects, in therelationship with commissioners, but the North West London Cardiac and Stroke Network hasidentified the specially identified professional needed to effectively repatriate with documentationpatients receiving PPCI from surrounding districts to a ‘heart attack’ centre.Commitment to submit data to National Audit of Cardiac Rehabilitation (NACR) is universal amongnetworks, and four of the projects make specific reference to network commitment to improvesubmission of data. The vital need to interface NACR with other important cardiac databases is alsoemphasised.The inequalities’ agenda is ever reflected in access to cardiac rehabilitation. All projects have bravelytackled variation both within and among programmes, and between different cardiac patientpathways. Their innovative approaches involving all stakeholders bear witness to our network surveyoutcome that the majority have been able to favourably influence cardiac rehabilitation across theirregions.The 2008-2009 year has been a really stirring one, but there remains most yet to do! Best wishesfor the coming year!Jane Flint BSc MD FRCPNational Clinical Advisor for Cardiac Rehabilitation to NHS Improvement www.improvement.nhs.uk/heart
  6. 6. 6 Cardiac Rehabilitation - National Priority Projects Introduction The National Priority We were also keen to ensure that the components Project for Cardiac indicated below were addressed: Rehabilitation started in September 2008 • Reducing inequalities following applications • Addressing diversity by cardiac • Increasing access to and information about CR networks and NHS services organisations and a • Engaging patients/carers/families in planning stringent review services process. Nine projects • Workforce and multi-disciplinary team were chosen – some approaches. of which had several strands of work and others which were pulling together different sites into one To share the learning a series of two monthly main project. meetings were initiated attended by project managers and their teams. Led by the national The overall aim of the national project was to project leads for cardiac rehabilitation at NHS increase the access to, equity of provision and Improvement, (Linda Binder, National Improvement uptake of CR services for heart attack, angioplasty Lead, Patrick Doherty, National Clinical Lead and and CABG patients, piloting implementation of the supported by Dr Jane Flint, National Clinical NICE Recommendations on Cardiac Rehabilitation - Advisor) these meetings proved a very successful as outlined in the NICE Clinical Guidelines CG48 on method of providing peer support. Learning from MI: Secondary Prevention and utilising the NICE other projects and about national issues, such as Commissioning Guide on Cardiac Rehabilitation as work around tariff negotiations, has proved a resource to support improved commissioning. invaluable to progressing individual projects within the national initiative. We were particularly interested in receiving applications where the focus would be on: One year into this three year national project, the project sites are keen to share their outputs to • Identification and active engagement of eligible date. These range from projects whose work CR participants using a systematic and structured around commissioning (and with commissioners) approach has led them to develop a service specification - • Development of mixed models of provision and in one instance set up a tendering process - tailored to meet the needs of individual patients to others where the pathway has been examined, • Relevant rehabilitation for groups less likely to renegotiated or been subject to demand and access the service such as women or ethnic capacity work within the service in order increase minorities the numbers and types of patients accessing • Development of exercise components designed rehabilitation. to meet the needs of older people or those with significant co-morbidities The quantifiable benefits are outlined within the • Joint agreement, planning and commissioning of projects and summarised in terms of key learning services across hospital trust, GP practice, PCT and QIPP outcomes. Further detail on these points and social/leisure services and at network wide is contained in the project summaries that follow. level • Exploration of the feasibility of a generic rehabilitation model encompassing other disease modalities. Linda Binder National Improvement Lead, NHS Improvementwww.improvement.nhs.uk/heart
  7. 7. Cardiac Rehabilitation - National Priority Projects 7Key LearningOutlined below are some of the key learningidentified by the projects after just one year:• Ensure supportive and strong clinical leadership/engagement to champion the approach, aid decision making and manage clinical expectations of the group• Ensure the right people are working on your project and that you are engaging with the right stakeholders from the outset• Understand baseline activity of existing service provision and ensure there is robust data - crucial to help identify inequalities and to monitor progress of work• Build analyst time into your project and make sure your finance team are also on board if necessary• Understand your demand and capacity• Ensure service reconfiguration does not create an alternative bottleneck• Spend time defining your key performance indicators• Good communication mechanisms (email / phone) helps resolve issues quickly• Build sustainability into your service• Learn from other trusts that are doing well, a site visit is often a good way of doing this• Promote the ability of cardiac rehabilitation to reduce admissions and length of stay and generate cost savings into your business case• Consider the implications of going out to tender and whether you will need to buy in external consultancy• Dedicated project management time• Multiagency partnerships can increase flexibility within your service• Don’t forget the patients – their views are important and helpful in redesigning a service. www.improvement.nhs.uk/heart
  8. 8. 8 Cardiac Rehabilitation - National Priority Projects Quality, Innovation, Productivity and Prevention (QIPP) Outlined below are some of the QIPP benefits INNOVATION identified by the projects after just one year: • Rehab led follow up QUALITY • Looking at ways to include health checks • Drug therapy reviews Safety • Task group acting to coordinate all quality • Centralised referral and patient tracking initiatives. • Standardised protocols and procedures assessed against evidence base PRODUCTIVITY • Risk stratification form • Criteria for shuttle testing patients • Increased number of patients accessing rehab • Governance standards developed with • Reduced hand offs – integrated team with fewer metrics system referral steps • Skills competency assessment. • Using and scheduling staff more effectively • Rehab led follow up – reduces the need for Effectiveness outpatient attendance • New community and home based programme • Ensuring availability of MDT staff to for IHD increase flow. • Cardiac rehabilitation outcome measures identified • Clear management plans • Effective use of staff and programmes – no shutdown of services. • ICD rehab (rolled out) • Rehab led follow up. Experience • Increased patient choice • Care provided closer to home • Relevant patient information • Discovery interviews, patient forums and patient questionnaires to inform development of services which meet patient needs.www.improvement.nhs.uk/heart
  9. 9. Cardiac Rehabilitation - National Priority Projects 9 Project Summaries
  10. 10. 10 Cardiac Rehabilitation - National Priority Projects Commissioning an equitable service across the county Derbyshire County PCT Synopsis • No clear funding streams. Historically the majority of budgets have been tied up within Our challenge was to commission an effective, acute trust contracts. The lack of clear funding consistent and equitable cardiac rehabilitation streams has meant that the cost of cardiac service across Derbyshire PCT by providing care rehabilitation varies across the PCT and does closer to patient’s homes and offering them a not always represent good value for money. menu based service. • Lack of data to support cardiac Over the course of two years we have aimed to rehabilitation. Not all of the service providers identify our baseline, develop a new model of that provide cardiac rehabilitation for service, ‘build’ a business case to secure funding, Derbyshire patients use the NACR database develop a service specification and procure the and data varies enormously in terms of quality. service through a formal tendering process. The lack of a centralised system has meant that data has not been able to be used to To date we have secured funding for the service ensure everyone eligible for cardiac and we are preparing to go out to tender before rehabilitation has been offered it. the end of 2009. Background Current service provision for people resident in Derbyshire The merger of six PCTs to form Derbyshire County Primary Care Trust (PCT) in 2006 led to a differing level of provision of cardiac rehabilitation across the health community. The large and diverse PCT has meant that patients have been receiving rehabilitation from a variety of service providers, many of which are located outside of the PCT boundary. In 2007 a strategy was developed to identify the main issues facing cardiac rehabilitation services in Derbyshire, these are summarised below: • Inequitable service. There is no consistent cardiac rehabilitation pathway across Derbyshire; therefore it is the geographical location of the patient that has determined the service received. The lack of a coordinated approach towards rehabilitation has meant that programmes have not been distributed • The stars in blue are community services that equitably in response to need; analysis has provide cardiac rehabilitation phase 3 only shown that in the area with the highest • The green stars show the number of acute prevalence patients were expected to travel provider services that our patients in some of the largest distances to access a Derbyshire can access. Some of these also programme. provide a phase 3 programme. However, • Poor uptake. In some areas of the county it apart from the two main provider trusts in was identified that there was a poor uptake the county many patients find the distance rate. This was most notable in the Bolsover to travel back to the other provider trusts challenging and therefore for our patients Spearhead area, where it was calculated that there is little uptake of the phase 3 as little as 16% of eligible patients were taking provision. up cardiac rehabilitation. Contributing factors are thought to be; distance to hospital based programmes, associated parking charges and lack of choice of programmes available.www.improvement.nhs.uk/heart
  11. 11. Cardiac Rehabilitation - National Priority Projects 11What we did The steps taken to achieve the aim and planned outcomes of the project are summarised below:The aim of the projectThe aim of the project is to commission an a.Baseline measurementeffective, consistent and equitable cardiac Work commenced to understand our currentrehabilitation service across Derbyshire in order levels of activity and financial commitment.to optimise uptake and maximise health This was challenging due to the number ofoutcomes for the population. providers, complicated financial arrangements and variation in data collection.Planned outcomes for the project b.Development of a new cardiac• Increased access: the service is moving rehabilitation pathway for Derbyshire towards a menu based model whereby A work group consisting of clinicians from the patients will be able to choose a service that major providers, commissioners, public health meets their individual need. This will optimise specialists and a patient representative came uptake and provide more patient centred care. together to develop a new pathway for The planned increase in community based Derbyshire County PCT residents. A clinical provision will reduce the distances people lead who works across both primary and currently are required to travel and as a result secondary care was appointed and her role increase access. The referral criteria will include was critical in leading the development. Some angina and heart failure patients, two groups of the actions the group took to facilitate the who are not consistently offered cardiac development of the pathway included: rehabilitation at present. • Process mapping with clinicians and patients• Reduction in health inequalities: service • Brainstorming what an ideal pathway should provision will be planned in accordance with look like against national evidence and best the greatest health need, taking into account practice disease prevalence, deprivation and access. A • A site trip to a cardiac rehabilitation service menu based service will ensure that people are reporting high uptake and good outcomes not excluded from cardiac rehabilitation • A patient representative working with us because they choose not to attend a formal, throughout the project. group programme. c. Identification of additional funding• Increased links with primary care and long A business case was developed by term maintenance options: community commissioners outlining the key issues and based services will support the development of risks with the current service and identifying stronger links with the communities that potential benefits and savings to the PCT. patients live in. The new pathway will seek to d.Development of a service specification ensure a seamless transfer of patients into Additional funding was secured through the long term healthy lifestyle options as well as PCTs Local Operating Plan for 2009-10 and making sure that all patients receive structured work commenced to translate the pathway follow up by primary care. into a service specification and define key• Increased effectiveness: the service will be performance outcomes. commissioned with a focus on outcomes. This e.Commencement of a procurement process will ensure delivery of the health benefits that to drive improvement cardiac rehabilitation can provide. Due to the number of existing providers, the• Increased financial effectiveness: the new potential value of the contract and the level of pathway will seek to standardise the cost of service redesign it was decided that a formal cardiac rehabilitation across Derbyshire so that procurement process would be the best value for money can be achieved. It is method for securing the best health outcomes anticipated that by commissioning for both and value for money service. activity and health outcomes service providers will be driven to deliver quality care and efficiencies. www.improvement.nhs.uk/heart
  12. 12. 12 Cardiac Rehabilitation - National Priority Projects The biggest issue/challenge a.Ensure the right people are working on your project and that you are engaging with the Defining the baseline was crucial to identifying right stakeholders from the outset of the the amount of activity to be commissioned and project. These may include cardiac to understand the local picture. It proved rehabilitation clinicians, public health, GPs, extremely difficult to calculate the current spend finance, HR, information, leisure services, on cardiac rehabilitation services because of the support groups, cardiology etc. lack of clear funding streams. In one case, b.Understand what is currently happening in investigation by one of the acute trust service your PCT in terms of baseline activity and providers highlighted the fact they had not been understand how it is being paid for. Build charging the PCT at all for the activity. Getting analyst time into your project and make sure reliable and accurate data on the number of your finance team are also on board to assist. patients who would be eligible for cardiac c. Consider early the possibility of going out to rehabilitation and understanding which patients tender and communicate this to your were already accessing the different pathways stakeholders. was also a complicated process. Both tasks took d.Ensure you have strong clinical leadership but longer than expected and required significant consider the implications of going out to finance and analyst input. tender and whether you will need to buy in The impact to date external consultancy. e.Build a business case and make sure you This project is about planning for and promote the ability of cardiac rehabilitation to commissioning a new cardiac rehabilitation reduce admissions and length of stay and service. To date the key success factors include: produce cost savings. • Development of a new pathway f. Learn from other trusts that are doing well, a • Securing additional funding in order to site visit is often a good way of doing this. implement the new pathway g.Spend time defining your key performance • Development of a service specification. indicators. Allow potential providers to be innovative in their response to your service The service specification will ensure that the specification. impact of the service, once commissioned, will h.Dedicated project management time. be able to be measured by commissioners on a Next steps regular basis. This will include: • Activity – up take rate against national targets, The new pathway for cardiac rehabilitation is decliner rate, completion rates, referral rates to expected to be commissioned by the PCT via a other services formal tendering exercise within this financial • Health outcomes – patients will be expected to year. The successful provider or providers will achieve a certain number of health outcomes then work with the PCT to implement the new including, treatment outcomes, clinical pathway through a phased approach over the outcomes and patient centred outcomes following six months. • Quality outcomes such as accessibility of the Contact details service, patient and carer satisfaction, compliance with national standards and Ciara Scarff, Long Term Conditions waiting times etc. Commissioning Manager Email: ciara.scarff@derbyshirecountypct.nhs.uk Barriers, challenges, and lessons Telephone: 0115 9316159 Key learning points from Derbyshire County Janet Whitehead, Public Health Specialist PCT project: Email: janet.whitehead@derbyshirecountypct.nhs.uk Telephone: 01629 817931 x2316www.improvement.nhs.uk/heart
  13. 13. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTLUNG NHS Improvement With ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainableSTROKE effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart and stroke services. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Delivering tomorrow’s improvement agenda for the NHS ©NHS Improvement 2009 | All Rights Reserved - Publication Ref: IMP/heart09/02
  14. 14. Cardiac Rehabilitation - National Priority Projects 13A sector wide approach to cardiacrehabilitation in South West LondonSouth West London Cardiac and Stroke NetworkSynopsisWhat was the problem, challenge or issueyou were trying to resolve?The network’s cardiac rehabilitation task grouphad agreed on a high level pathway for cardiacrehab services (see appendix 1) and wantedsupport from the network to implement thisacross the sector. In addition, they soughtsupport in establishing robust commissioningarrangements for their programmes.What were you trying to achieve in thetime available?As the scope of this project is broad (covering allcardiac rehab programmes in the sector) we feltit was realistic to focus on project planning and was successful, with a lot of positive feedbackstarting to pilot initiatives during the first year, received and work is now progressing to agree awith ongoing evaluation and roll-out of pan London set of outcomes for cardiac rehab.successful initiatives running into the second What would you do differently?and third years of the project. The initial focus of the project was on theWhat was your solution(s) or approach incoming phase one tariff as programmes in theto this? sector were keen to look at implications of this.Our approach has been two-pronged. New In retrospect, the initial work should haveinitiatives are being trialled using a PDSA cycle focused on ensuring all teams had robust databased approach (plan, pilot, review, and to inform commissioners and to support shadowroll-out). In addition, the network team agreed modelling of tariff once agreed.to support service redesign work that had Also, tighter project planning in the early phasesalready commenced, ensuring that the agreed for elements which are reliant on others topathway was firmly embedded in this work. deliver would have enabled us to be clearerWhat worked/ didn’t work to date? about roles and responsibilities and manage theSo far, the approach we have taken to piloting process more firmly.and rolling out initiatives has been successful.We have had been able to implement initiatives Backgroundthat have worked well in other areas, using the The idea for this project arose from the findingslearning from pilot sites to support this. We have of a retrospective audit of cardiac rehabalso trialled some initiatives in one or two sites programmes in South West London, and an(such as ward staff delivering phase one) and assessment of these programmes against thefound these to be less successful and therefore NSF and the BACR standards (appendix 4).these have not been picked up post-pilot. These indicated that there was a range of rehabInvolvement in the national priority project has provision across the sector, with inequalities inbeen very valuable to stay abreast of what’s provision for different groups. In addition,going on both at a national level and in other cardiac rehab services across the country areorganisations from across the country. striving to provide a ‘menu’ of rehab options, to promote onward referral to existing preventionWork on the commissioning and tariff services, and to increase the range of settings inworkstream has been slow, partly due to the which rehab is provided. The aim of this is tolack of information available about the tariff. provide services which are more flexible and canHowever, a pan London event focusing on the be tailored to fit patient needs more easily,commissioning of cardiac rehab services in May thereby increasing uptake. www.improvement.nhs.uk/heart
  15. 15. 14 Cardiac Rehabilitation - National Priority Projects Research findings and local patient feedback Metrics have been developed for the cardiac indicate that patients feel most vulnerable in rehab workstreams of both South London the early post discharge phase and this is most network workstreams, which will be reviewed evident in patients who spend short periods of for sign off in September 2009. These have time in hospital (such as primary angioplasty been aligned with the project measures to patients who have an average length of stay enable ongoing measurement of impact and of three days). The network task group monitoring to ensure sustainability (see therefore developed a high level pathway for appendix 3 for the draft dashboard). implementation (see appendix 1). The key features of this pathway are the emphasis on This project has taken a sector wide approach the early post discharge phase, the range of which has been beneficial in working towards options available, the range of settings available, reducing inequalities and supporting programme and the links with existing prevention services. leads to progress service improvement work. The aims and anticipated benefits of the project Pan London work has also commenced to are outlined in appendix 2. develop a joined up approach to the key issues for rehab services, promote networking, to What we did support joined up working between providers in different sectors, and to ensure some The baseline data for this project was taken standardisation in the commissioning of from the retrospective audit and baseline CR services. assessment conducted in 2007. Workstreams were developed in conjunction with the task The aims of this project were: group, and have evolved as the project has gone • To improve access to cardiac rehab for all on to reflect changes locally (i.e. within existing groups of cardiac patients services) and nationally (i.e. tariff development). • To reduce inequalities throughout the sector Pilot sites for initiatives were selected based on • To improve uptake by providing a sector-wide enthusiasm of programme leads, fit with service that is responsive to the needs of ongoing work (redesign work and other patients and clinicians initiatives currently underway) and an • To ensure providers and commissioners are assessment of need (e.g. drug therapy review working together to plan, develop and pilots will be selected based on audit results). commission appropriate services for local populations. Initiatives are being implemented through a pilot, evaluate and roll-out approach and The key high level outcome of this project was through integration with service development that all communities in the sector have high and service redesign work already underway. quality, robustly commissioned CR services It is anticipated that the pathway will be providing a range of activities in a range of embedded throughout the sector once settings that can be equitably accessed by all workstreams have been evaluated and the groups of patients that can benefit. The aims learning from these shared amongst the and anticipated benefits of the project are organisations in our sector. The project leads outlined in appendix 2. plan to drive and embed ongoing service improvements through supporting robust commissioning of CR services in our sector.www.improvement.nhs.uk/heart
  16. 16. Cardiac Rehabilitation - National Priority Projects 15The biggest issue/challenge Work to reduce inequalities in access to CR for different patient groups is progressing well inThe network task group has a quality assurance many areas, including the development of arole for rehab programmes in the sector and this number of new programmes.has led to unplanned involvement inprogrammes undergoing changes which have • A successful ICD CR pilot has enabled sectordestabilised other local programmes. However, wide roll out to commencethis has clear links to the project as ensures • A new community IHD CR programme hasequity of provision across the sector. commenced targeted specifically at hard to reach populationsThe quality assurance role has been essential to • A new community programme incorporatingthe delivery of the project as services in heart failure rehab has been developed withdevelopment and those undergoing significant network support (recruitment almostchange are taken to the network task group to complete, programme to commence autumnenable them the group to have oversight of CR 2009)services in our sector, allowing them to assess • A local PCT has agreement to develop a stableequity of provision. This role was signed off by angina community CR programme, supportedchief executives in the sector and enables our by discovery interviews conducted by networktask group (professionally and organisationally leads.representative) to input to local decision makingfrom a clinical perspective. In addition, existing programmes have begun to broaden their inclusion criteria, enabling moreInvolvement of the project leads in quality patients who can benefits from cardiac rehab toassurance activities has been particularly time access services.consuming and has adversely affected timescales for the project as several initiatives have The scope of this project means that lead in timehad to be placed on hold while issues are for delivery is much longer than for projects withresolved. This has, however, been essential to a more discrete focus, however this means thatachieving the project objectives and although the impact and benefits of this work oncesome of this work has been unplanned, and realised will be much broader. It is anticipatedsomething we were unable to anticipate, it is that this project will impact on patient outcomeshas been important in helping us to achieve the (such as quality of life, knowledge of theirend project goals. condition, risk factor modification, etc as well as mortality and morbidity), process of careThe impact to date outcomes, resource utilisation outcomes (such as onward referral to services such as smokingThe scope of this project means that many cessation) and cost outcomes. It is envisagedinitiatives are still at the planning or early that the impact of the project of some of theseimplementation stage. Preparatory work has outcome measures may not be noticeable in theincluded: short term but these will be reviewed one year• Business case development after project work has finished.• Project planning for drug therapy review The impact of this project is being measured (including South London audit) and rehab led through the South London cardiac rehab follow up (pilots to commence later this year) workstreams dashboard. This measures the• Skills competency assessment tool impact at a high level as the scope of the project development using Skills for Health CHD is broad (sector wide), with the recommendation competencies (used with two teams to identify that local / workstream level data be measured training needs in relation to the new pathway and monitored locally through NACR. For and has been shared with national priority example, the dashboard monitors which groups project colleagues). of patients are able to access cardiac rehab in www.improvement.nhs.uk/heart
  17. 17. 16 Cardiac Rehabilitation - National Priority Projects each borough, with a recommendation that Key challenges/ barriers to programmes use NACR to monitor activity data implementation/ risks to delivery for different patient groups. and how you overcame them A major challenge for this project has been the Barriers, challenges, and lessons lack of robust data available to us. Better data would have been immensely helpful to support What worked and what didn’t work; what commissioning discussions. A lack of you would do differently/ the same; understanding by individual programmes Pan London working has been very useful, regarding their funding streams has been a enabling us to minimise duplication, develop particular hurdle as this has had to be clarified contacts and network effectively, and provide whilst trying to avoid leaving unfunded the London networks with an approach to programmes in a vulnerable position. The pan tackling inequalities in cardiac rehab provision London work on developing outcomes for more easily. A pan London cardiac rehab cardiac rehab has also been hindered due to the conference was successful, with positive lack of robust data and the approach altered to feedback from delegates who felt that this allow for a ‘shadow period’ to help identify improved their knowledge of the commissioning realistic parameters for outcome measures. process. Delegates also felt that developing a pan London set of outcomes for cardiac Key learning/sharing points rehabilitation was an important piece of work and that networks were in a position to support Leadership and planning this. Our clinical lead has been very supportive of this project and has been involved in project decision An initiative to pilot role changes for phases one making and championing the approach. We and two was not successful. The aim of this was have a cardiology lead on our group who has to have ward nurses provide phase one input, helped us with applying our quality assurance thereby freeing up the time of the rehab team role to programme changes in the sector. to focus on a delivering a more comprehensive phase two service. This was unsuccessful due to Joined up working with other network the lack of time for the ward nurses to provide a workstreams has been very productive. For full phase one service. In addition, it became example, our patient diaries project has run evident that this did not fit well with incoming across the revascularisation and rehab tariff once the tariff costs were confirmed. In workstreams, with the diaries being completed retrospect, it would have been better to assess from pre-assessment, through the inpatient stay more closely staff capacity on the wards, to wait and throughout the rehab phase, giving us a full until tariff information was clearer, and to run a picture of the pathway and not just the rehab skills competency assessment with key staff element. before commencing this initiative. Clinical engagement This project has taken a broad approach to Clinical engagement has been essential in patient involvement and this has been very driving this project. Involvement of local cardiac helpful in informing the project direction to rehab clinicians in the development of the date. A decision was made not to have a patient pathway prior to the project commenced representative on the task group but to have a definitely helped to achieve early buy-in. This has liaison member from network patient group and also ensured that programmes in the sector had to have a range of mechanisms for patient early consensus on the project goal/end point. involvement tailored as appropriate. The aim of In addition, the group has an enthusiastic and this was to gain a broader picture of the patient supportive clinical, and is organisationally and and carer perspective of rehab services and professionally representative, both factors which pathways, and to avoid tokenistic have been essential to decision making and representation. Appendix 4 outlines this implementation. approach.www.improvement.nhs.uk/heart
  18. 18. Cardiac Rehabilitation - National Priority Projects 17Information transfer Work to address health inequalitiesOur task group meets every six-eight weeks We have found that having a good baseline ofand this has been the forum for project issues existing service provision and robust data isto be discussed. We have found interim crucial to help identify inequalities and tocommunication (email / phone) as well as being monitoring progress of work aimed atavailable for ad hoc discussion has helped reducing these.resolve issues quickly. Within the network teamwe have used our NPP monthly reports and the Next stepsNHS Improvement System to communicateproject progress. We will continue with the approach outlined previously, ensuring that this is supported byFor initiatives that have multiple leads and robust evaluation processes and that themultiple organisations involved we have found learning from each initiative is sharedit really useful to have a set of communication appropriately. We plan to monitor progress at atools that clearly articulate the background, sector wide level through the South Londonapproach and plan for the work. For example, dashboard, which will be signed off in autumnthe drug therapy reviews pilot is being set up by 2009, along with a set of governancenetwork leads from South East and South West requirements. A South London leads group willLondon along with the pharmacy lead that be established to support this and to take aworks across these networks. Early in the project strategic overview and to help align thewe produced a PID and a briefing paper that workstreams.have been used for meetings with network taskgroups, potential pilot sites, and industry links, We will continue to review progress in anensuring consistency of communication and ongoing manner with pilot and roll out sites tominimising duplication of effort. help embed and sustain this work. We anticipate the task group as having a key role in sustainingProvision in community settings changes and rolling out good practice.There are a number of community cardiac rehabservices in our sector now, with several more in Contact detailsdevelopment. An important learning point for ushas been around ensuring that these are joined Alice Jenner,up with other programmes (e.g. hospital based Project Manager,programme and existing prevention schemes) South West London Cardiac and Stroke Networkright from the beginning. Wherever possible Email: alice.jenner@stgeorges.nhs.ukteams should be in a position to cross-cover to Tel: 020 8725 0956maintain flexibility and consistency in provision. Michelle Bull,For small teams these links can also help prevent Senior Project Manager,professionals feeling isolated by promoting South West London Cardiac and Stroke Networkshared learning and peer support. In boroughs Email: michelle.bull@stgeorges.nhs.ukwith multiple CR providers it is also very Tel: 020 8725 1192important to ensure there is clarity and goodcommunication about patient choice and referralroutes. The project team are currently producinga strategic vision paper to inform commissioners NB: Appendices 1-4 are available fromat hub level regarding cardiac rehab provision. the NHS Improvement website at: www.improvement.nhs.uk/heart/ rehabprojectsummaries www.improvement.nhs.uk/heart
  19. 19. 18 Cardiac Rehabilitation - National Priority Projects Rehabilitation triage assessment North Lincolnshire and Goole Hospitals NHS Trust Synopsis into two sections one is looking at current demand and one looking at attendance against What was the problem, challenge or issue attendance. you were trying to resolve? We noted that patients were not getting timely Background access to their cardiac rehabilitation. This appears to have resulted from the fact that we The priority project initiative is to triage as nurses have stopped attending a secondary participants into appropriate cardiac prevention clinic run by the medical team; and rehabilitation, using a structured pre-assessment also as patients are transferred to other hospitals and follow up evaluation. Prior to the project for intervention they are not always referred patients were put on a waiting list for exercise. back in a timely manner. The waiting list dates back to 2001, we have made several attempts to try to address waiting What were you trying to achieve in times, but have been unsuccessful. However, the time available? during this time the service has expanded to We were trying to ensure that patients receive include angioplasty and heart failure patients, timely and appropriate access through triage to with a year on year increase in service users. Due phase three cardiac rehabilitation. This will to the time on the waiting list we find that some reduce inequalities in accessing the service and patients have declined to undertake exercise by so improve patient’s quality of life. To be able to the time we are able to bring them into the give patients a date for pre-assessment in programme, either because they have started advanced without having to be added to a exercising on their own, or they are back at waiting list. work and do not feel that they would benefit What was your solution(s) or approach from an exercise programme. We have increased to this? our capacity for exercise by now providing • We intend to use the national audit for community based exercise programmes and a cardiac rehabilitation database as a backup home based programme from a British Heart for those patient’s who have had a procedure Foundation/Big Lottery grant. We initially in another hospital thought that this would help us to address these • We have changed our paperwork issues in people having to wait to start the • We have developed a flow chart to ensure exercise programme; however, we have found that we are all working to the same guidelines that we now have a longer wait to access the and standards so that all patients have equal programmes. Our team felt the national priority access at the appropriate time. project initiative would give us the required framework to look at our service and help us to What worked/didn’t work to date? highlight the relevant issues in order for us to We attempted in spring 2009 to undertake a make the appropriate changes. piece of demand and capacity work which was supported by our cardiac network. However, due What we did to staffing issues within the department we were unable to complete this piece of work The aims and objectives of our project are to successfully. Since June 2009 these issues have triage participants into appropriate cardiac been resolved. We have not attempted to rehabilitation, using a structured pre-assessment recreate the original piece of demand and and follow up evaluation. This will benefit the capacity work as our service configuration has patients by enabling them to have timely and changed. appropriate access through triage to physical activity; improved quality of life for individuals, it What would you do differently? will provide an ideal opportunity to signpost Capacity and demand work would have been individuals to other aspects of the cardiac managed differently, we feel that this was too rehabilitation service, and provide an opportunity large a piece of work and should have been split to re-enforce key health care messages. into two smaller pieces. We have now broken itwww.improvement.nhs.uk/heart
  20. 20. Cardiac Rehabilitation - National Priority Projects 19The expected outcome measures are: Demand and capacity• An improved quality of life measured via We have now revised the demand and capacity hospital anxiety and depression (HAD) score work; as this was not as successful as we had• A reduction in service utilisation by this group originally hoped, due to staffing issues, and the of individuals, (reduction in readmission, out need to change our service configuration. We patient follow up and consultations) have changed our registers for the programmes,• Flexibility of waiting time to attend the cardiac so that we are continually monitoring rehabilitation programme to meet the demand/capacity/uptake and unused capacity individuals needs on a weekly basis.• Improved physical function by an appropriate tool Allocation of pre-assessment appointment• A clear management plan for each individual We have now allocated designated slots for pre- which will be informed by discussion with the assessments, as we felt that with offering seven patient and their carers. different exercise programmes, the management of allocating these patients was left to oneWe have added some health outcomes into our person which often became overwhelming withguidelines for referral and entry into the cardiac other work commitments. At pre-assessment werehabilitation programme, for those who are able to discuss with the patient and theircomplete 70% of the phase three cardiac relative what their needs are, and make anrehabilitation exercise programme there should appropriate plan to meet their needs. We do thisbe evidence of benefit in two out of four of: through an assessment of their lifestyle; record• Improvement in functional capacity test their blood pressure and pulse; undertake a by 10% functional capacity test; all patients complete a• Improvement in HAD score by four points NACR questionnaire, and a risk assessment is• A measure of continued exercise either by carried out using the BACR risk assessment tool. referral to phase four sessions or individual Once we have all this information we discuss programmes with the patient and relative where is the most• Attainment of more than one risk factor appropriate place for them to exercise. treatment goal (eg stopping smoking, reducing cholesterol, reduction in blood Individual programme manager pressure). We now have split up the management of the exercise programmes, and pre-assessmentProcess mapping allocation, so that each member of the team hasFirstly we process mapped our service with the a specific programme that they manage. Thehelp from the cardiac network. The process map team then meets on a weekly basis and eachhighlighted the fact that we needed to program leader updates the rest of the team onundertake some demand and capacity work, as their specific programme. We also discuss eachwe were not able to highlight where the barriers patient who has been highlighted as fit andwere regarding the patients having timely access interested to undertake the exercise componentto their cardiac rehabilitation. It also highlighted of cardiac rehabilitation. If we notice at thesethe issues we have in relation to those of our meetings that there is a wait starting to developpatients who have a complex journey, which at one particular programme, we will discuss ifprevents us from identifying the point at which there is any capacity elsewhere and offer thethey are suitable to undertake the exercise patients an alternative site. Each programmeprogramme. This is often due to patients being leader will then make an appointment for thetransferred to our tertiary centre for further patients that are relevant to their programme ininvestigations and procedures, and they are not order for the patient to be assessed fully.always referred back to us. This has lead tofurther work which is network wide to focusaround referrals back to each hospital, thecardiac network are assisting and supporting usin this work (see appendix 5). www.improvement.nhs.uk/heart
  21. 21. 20 Cardiac Rehabilitation - National Priority Projects The biggest issue/challenge Challenges remain regarding identification of patients who are ready to exercise but who experience a complex patient journey. We feel that one reason for this is because our main tertiary centre has a high patient workload but a limited cardiac rehabilitation service. The referral of our patients back into our service is not seen as a priority by their nursing teams. One issue identified through the project was our inability to quantify demand against capacity. As already identified we were unable to successfully complete this piece of work. We have not attempted to recreate the original piece of demand and capacity work but have changed the focus to monitor attendance against capacity and unutilised capacity. Work undertaken during the project has identified the programmes running with unused capacity. We were able to identify that this was due to our management of the existing patient The waiting list for the seated exercise pathway. The impact of our action/inaction programme will remain as this group of patient’s created a waiting list and caused us to ‘fire fight’ ability to exercise can be affected by non cardiac to reduce waiting times rather than having a reasons causing the group to change at short clear long term strategy to promptly identify notice. However to optimise attendance we have patients who are ready to attend an exercise developed a 10 week rota. programme. We are now able to consider the introduction of Prior to the project one person managed all the a programme specifically for heart failure exercise programmes. This created an issue patients. By managing our demand and capacity when workload increased. The identification of better will enable us to utilise our resources patients suitable for exercise became differently to enable us to offer our Heart Failure inconsistent, pre-assessment dates were not patients a specific programme in the future requested in a timely manner and if patients rather than including them in the gym with non cancelled their appointment we were not heart failure patients. consistently reallocating the appointment to Working in partnership with local service another individual. providers has enabled us to fast track patients through Phase three exercise onto phase four The impact to date programmes when appropriate resulting in We no longer have a waiting list for our increased capacity in the Phase three Scunthorpe and community programmes. All programmes. patients are allocated a pre-assessment date We are currently developing flow charts by within one week of being identified as being which all team members can identify which suitable for exercise. programme is appropriate for each patient. The The issues which created a waiting list at the flow chart will identify a pathway for complex Goole programme are almost resolved. Our patients to enable us to identify when they are target is that by 31 October 2009 there will be ready to attend an exercise programme. no waiting list at the Goole programme.www.improvement.nhs.uk/heart
  22. 22. Cardiac Rehabilitation - National Priority Projects 21Each programme has an identified programme partnership with our local cardiac network andcoordinator who manages and monitors partner agencies to work out a long termdemand, capacity, waiting times and attendance strategy to address this challenge.on a weekly basis. Key learning /sharing pointsAt our weekly team meeting each programme • Understand your demand and capacitycoordinator updates the rest of the team on • Ensure service reconfiguration does not createtheir programme. If a programme is not an alternative bottleneckrunning at available capacity we discuss the • Build sustainability into your servicerelated issues and agree a strategy to prevent • Multiagency partnerships can increasecapacity wastage. (see appendix 6) flexibility within your service.Barriers, challenges and Lessons Next stepsWhat worked/what didn’t work • Our ability to assess health outcomes andThe process mapping exercise plus demand and develop a strategy for follow up evaluation hascapacity work has given us a better been hampered by staffing issues within ourunderstanding of patient flow through our department and the need to reconfigure ourservice. The team can now see how our demand and capacity workaction/inaction impact on waiting times for • Our team together with our local cardiacpatients ready to access cardiac rehabilitation. network is developing a prompt and reliable referral pathway for post intervention patientsWe have revised our demand and capacity work discharged from our tertiary centreto reflect current practice. Staffing issues within • We intend to commence collecting healththe department, which are currently in the outcome measure dataprocess of being resolved, resulted in • The second year of the project will concentratereconfiguration and suspension of some on these elements of our project.programmes in spring 2009. Although the teamrecognize this was not ideal we felt it was better Contact detailsto offer the majority of patients some ratherthan no rehabilitation. Louise Bevington Acting Lead Cardiac Specialist NurseChallenges/barriers Cardiac RehabilitationA challenge for the future success of our projectis to ensure that when making changes to our Email: Louise.Bevington@nlg.nhs.ukservice to meet the project aims and objectives Tel: 01724 290093that we do not create an alternative bottle neckin the patient journey.Our cardiac rehabilitation team has been stable NB: Appendices 5-6 are available fromfor several years however there have been recent the NHS Improvement website at:unavoidable changes within the team. One www.improvement.nhs.uk/heart/consequence has been the need to re-evaluate rehabprojectsummariesthe sustainability of our service. The team feelthat these issues and changes prevented usmaking the progress in the project that weenvisaged in the first year of the project.A long term barrier to the success of the projectis the continued delay in the referral pathwayfrom our local tertiary centre. We are working in www.improvement.nhs.uk/heart
  23. 23. 22 Cardiac Rehabilitation - National Priority Projects Planning cardiac rehabilitation commissioning Dorset Cardiac and Stroke Network Synopsis Background What was the problem, challenge or issue Pan-Dorset serves a population of 758,000 and you were trying to resolve? this project involves three Acute Trusts: Royal To fully understand the current cardiac Bournemouth NHS Foundation Trust, Poole rehabilitation service across Dorset so that Hospital NHS Foundation Trust and Dorset all programmes are supported to reach the County NHS Foundation Trust. The three cardiac minimum BACR Standards and Core rehabilitation programmes vary in length, Components (2007). content and the place of delivery. All programmes access cardiac rehabilitation phase What are you trying to achieve in the time one and two in secondary care. available? The project will take into account the NICE Dorset is a rural location and offers phase three Commissioning Guide for Cardiac Rehabilitation programmes in four community sites. (2008) in terms of determining local service Bournemouth offers phase three in secondary levels, developing a service specification and care only and Poole offers phase three in both building on mechanisms for quality assurance. secondary care and in the community. What was your solution(s) or approach to this Cardiac rehabilitation across Dorset is offered The cardiac rehabilitation service across Dorset routinely to only three of the many diagnostic will jointly agree a minimum service specification groups who might benefit. Such as those who which will form a basis by which all future undergo cardiac surgery, have a heart attack, services will be commissioned to ensure equity and those who have percutaneous coronary for all patients who require cardiac rehabilitation Intervention. Patients with heart failure, angina, across Dorset valve disease and have cardiac implantable devices are not routinely offered cardiac What worked/did not work to date? rehabilitation. The project has been well supported by commissioners and clinician from primary and What we did secondary care. The cardiac lead nurses have also shown commitment and enthusiasm for We set up a Dorset wide cardiac rehabilitation driving the project forward and implementing sub-group to promote joint working and steer changes that have improved cardiac the project. The sub-group members involved in rehabilitation services. The national peer support the project include clinicians, commissioners, meetings have been well attended by the local authority, cardiac network team and nurses and by our patient representative. patient and carer representatives. What would you do differently? The Dorset Cardiac Network embraces the Have a clear project plan from the start, with principle that Patient and Public Involvement timeframes and specific roles and (PPI) should be central to service provision and responsibilities formulised. The initial bid and the development. The Dorset Cardiac Network has first six months of the project was managed by produced a paper detailing the PPI plans for this two different project managers. Learning service project (see appendix 7). In brief it includes how improvement methodologies has been valuable representatives will be empowered and to drive the project. supported in their role as members of the project team and also describes how various methodologies will be employed throughout the duration of the project to ensure that the views of local patients and carers inform the work of the project team on an ongoing basis.www.improvement.nhs.uk/heart
  24. 24. Cardiac Rehabilitation - National Priority Projects 23The key aims of the project – using a phased 4. Links should be improved with localapproach is to: community leisure services to support the• To improve access for all groups of cardiac provision of suitable phase four exercise patients programmes for cardiac patients in the• To increase uptake of cardiac rehabilitation community.• To minimise inequalities across Dorset• To meet the South West ambitions target The second step was to undertake an uptake which says: and access audit to identify the number of people receiving cardiac rehabilitation and the“By March 2011 at least 85% of people reasons why people did not take up cardiacwith a heart attack, bypass surgery or rehabilitation or complete the course. The two baseline assessments will form the basis ofcoronary angioplasty will receive cardiac ongoing work.rehabilitation.”In order to fully understand the local cardiac Each phase three cardiac rehabilitationrehabilitation services between September 2008 programme across Dorset was asked to collect– April 2009 an extensive audit and analysis of data on patients who had a cardiac event duringthe cardiac rehabilitation programmes across the sample period of 1 January - 31 MarchDorset was benchmarked against the British 2009. The analysis started in August when allAssociation for Cardiac Rehabilitation (BACR) patients in the sample group should haveStandards and Core Components (2007). completed the programme. Full results of the audit will be completed by the 30 SeptemberThe key findings from the audit received and published on the NHS Improvementcomments from members of the cardiac website. Preliminary results are availablerehabilitation sub-group and recommendations (see appendix 7).have been planned to address inequalitiesand aid service improvement. The biggest issue/challenge • Defining the South West ambition target wasRecommendations from the BACR Audit a challenge and caused much debate – the1. Patients should be offered choice of home, team were unsure if it meant 85% of patients community or hospital cardiac rehabilitation offered cardiac rehabilitation or 85% should programmes. The delivery of cardiac receive phase three cardiac rehabilitation. rehabilitation should be predominately based • There is no direct guidance that exists on what in the community, particularly for those proportion of a programme needs to be patients with mild to moderate risk. For completed to ensure efficacy. Comments from patients with more complex needs, referral Patrick Doherty National Clinical Lead by email to hospital based rehabilitation programmes are helpful to aid discussion: should be available. In both cases programmes should be arranged to maximise patient choice with regard to day, time and “If you are fortunate to run a venue. programme twice weekly for eight2. On completing the cardiac rehabilitation weeks or more then you could use 80% programme all patients should be provided because it will keep you within the 12 with information regarding existing voluntary sessions threshold (two sessions per groups, networks, psychological support so that patients can access for ongoing support. week for six weeks) which, via the NSF3. On completion of the cardiac rehabilitation for CHD and Joliffe et als review, is programme all patients should be provided considered the minimum a number of with a discharge management summary sessions related to efficacy. explaining diagnosis, recent blood pressure, cholesterol result, list of medications and recommended medication optimisation plan for the GP to follow. www.improvement.nhs.uk/heart
  25. 25. 24 Cardiac Rehabilitation - National Priority Projects The difficulty comes when you have set goals that require more time to achieve such as smoking cessation and weight reduction. Equally if you have patients with high levels depression/anxiety or those with difficulties taking on board secondary risk management behaviours it is important to ensure that they attend all sessions. It is easier to make up for a drop in exercise sessions in the community but less so for the education sessions. • Patient referral and pre-assessment letters have Programmes should try and ensure that been improved in response to patient all educational components are delivered information from patient discovery interviews prior to discharge”. • A pilot using the Heart Manual as a basis for phase three rehabilitation has been funded by Professor Patrick Doherty Dorset Cardiac and Stroke Network and is due National Clinical Lead, NHS Improvement - Heart to start in November 2009. • All three programmes are inputting data to the • Understanding the cardiac rehabilitation tariff National Audit of Cardiac Rehabilitation and has been difficult and remains a focus at the communication between the three sites has sub-group meetings. improved. • Nurses reported that although the network • A resource folder for services that patients can has funded staff ‘back fill’ for the project; the access has been updated at each site and nurses did not have the extra staff to fill whilst information of patient services across Dorset attending the national peer support meeting are shared. and local meetings. The nurses also found • Psychological services have been mapped allocating time for project work difficult at across Dorset and referral pathways to these times, specifically whilst undertaking the services have been identified. audits. • The nurses reported that the BACR and uptake Next steps audit was very time consuming and collecting the data was not easy as the information • Complete uptake and access audit and share needed was not accessible from the National results with the NHS Heart Improvement Audit of Cardiac Rehabilitation (NACR) data Team. Key findings from the audit will form base. recommendations that will aid service improvement and increase uptake and access The impact to date to cardiac rehabilitation. The project is still at its early stage of • Undertake Geo mapping exercise to identify development and many of the recommendations if any locations across Dorset show variation are at the planning stage or early in uptake. implementation stage. • All patients discharged from a programme will receive a management plan and this will be copied to the GP.www.improvement.nhs.uk/heart
  26. 26. Cardiac Rehabilitation - National Priority Projects 25• Introduce the Heart Manual as an additional method of delivery to support those patients who could not attend a traditional rehabilitation programme. It was agreed that this would be a pilot in the rural parts of Dorset. The patient experience and views will be recorded using discovery interviews.• Invite Leisure Services to join sub-group and be involved in the project to forge partnership working to expand the provision of phase four in the community.• Invite primary care colleagues to be involved in the project to improve seamless discharge from cardiac rehabilitation to the community.• Provide training to primary care colleagues on coronary heart disease lifestyle management to increase knowledge and awareness in order to empower patients to self manage.Contact detailsTracy Stoodley,Project Lead, Service Improvement Manager,Dorset Cardiac and Stroke Network.Email: tracy.stoodley@bp-pct.nhs.uk NB: Appendices 7-8 are available from the NHS Improvement website at: www.improvement.nhs.uk/heart/ rehabprojectsummaries www.improvement.nhs.uk/heart
  27. 27. 26 Cardiac Rehabilitation - National Priority Projects Modernising a cardiac rehabilitation service North of Tyne, North of England Cardiovascular Network Synopsis of the project. However, as the project progressed, it was recognised that sustained and What was the problem, challenge or issue frequent meaningful engagement with both you were trying to resolve? patients and professionals led to the project The North of Tyne area is geographically diverse, report being fully representative from a wide with densely populated inner city and remote range of stakeholders. rural communities, and includes spearhead areas of deprivation. The project aims to inform NHS What would you do differently? North of Tyne, to assist commissioning of a As previously mentioned, communication would patient centred, cost effective, equitable CR be more explicit at the outset as there was an service for patients having PCI, CABG and MI, element of uncertainty and concern about what acknowledging there are other groups who the review would entail – fears about tendering would benefit from rehab (HF, angina etc.). The for total service change and potential job losses objective is to resolve the differences in the were real issues for provider staff. It should have cardiac rehabilitation services already established been clearer at the start of the project that it in the three PCO areas and to move towards was a scoping exercise to produce a report to more individualised and accessible services. inform commissioning decisions rather than an end in itself. What were you trying to achieve in the time available? Background The current cardiac rehabilitation service was to be reviewed with a view to informing The project was a joint collaboration between commissioning decisions and addressing any the North of England Cardiovascular Network gaps and inequities in services, whilst actively and NHS North of Tyne. NHS North of Tyne is a engaging with stakeholders and patients in the joint management structure encompassing process. Alongside staff and patient involvement, three PCOs – North Tyneside, Newcastle and the project had to correspond and adhere to Northumberland Care Trust. It also covers two national policy drivers for the core standards of a acute trusts – Northumbria Healthcare NHS cardiac rehabilitation service. The next stage of Foundation Trust and Newcastle upon Tyne the project involves benchmarking providers Hospitals NHS Foundation Trust. NHS North of against the new service specification. Good Tyne commissions cardiac rehabilitation services practice would be highlighted and shared and for a large and diverse population of around any duplication in the patient pathways between 775,000 people and covers a geographically the different stages of care were to be diverse area including inner city and remote rural addressed. areas. NHS North of Tyne as a commissioning organisation has experienced the commissioner- What was your solution(s) or approach provider split at an early stage and as such the to this? commissioning functions of the PCOs are well Both patients and professional stakeholders established. representing community and acute settings were consulted with on a regular basis. Several The scope of the project was to map current stakeholder events were held to discuss the cardiac rehabilitation services and to include proposed service specification and also to patients who had MI, CABG and PCI ensuring comment on the ongoing project report. they had timely and equitable access to Patient focus groups within cardiac rehabilitation rehabilitation services in line with national services were also held along with GP interviews. policies and guidelines. This service was to be tailored to the individual and also needed to What worked/ didn’t work to date? respond to the requirements of a very diverse Communication with service providers in the population. The project spanned the entire initial stages of the review could have been patient pathway and focussed on the improved as it was felt that commissioners did community element of this, i.e. discharge from not keep professional stakeholders fully hospital. Each cardiac rehabilitation team was informed of the scope and proposed outcomes structured differently with some elements of thewww.improvement.nhs.uk/heart

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