Commissioning a cardiac rehabilitation service

Cardiac rehabilitation is a set of services that enables people with coronary heart disease (CHD) to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society. There is evidence that cardiac rehabilitation reduces the risk of total and cardiac related mortality, subsequent revascularisation and occurrence of non-fatal myocardial infarction (MI). Evidence also suggests that it results in improving people's ability to work, their physical capacity and their perceived quality of life. Cardiac rehabilitation is an established therapy and comprises mainly of supervised exercise training, relaxation and education.

Cardiac rehabilitation should not be regarded as an isolated form or stage of therapy, but be integrated within secondary prevention services. 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. Collaboration between primary and secondary care services is vital in order to achieve the best cardiac rehabilitation outcomes.

Cardiac rehabilitation is recommended, in NICE clinical guideline CG48 on MI: secondary prevention, as an appropriate intervention for people following a hospital admission for MI. This supports the ‘National service framework for coronary heart disease', which states that ‘every hospital in England should ensure that more than 85% of people discharged from hospital with acute MI or after coronary revascularisation are offered cardiac rehabilitation. 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 extend their rehabilitation services to people admitted to hospital with other manifestations of CHD'.

Therefore, although this commissioning guide focuses on cardiac rehabilitation for patients post MI, commissioners may wish to consider that such services can also provide benefits for people with stable angina or heart failure, and people undergoing revascularisation (before or after surgery, percutaneous coronary intervention or both ) or other specialised interventions (for example, heart transplant and surgery to fit implantable cardiac defibrillators).

Currently, many people who might benefit do not receive adequate cardiac rehabilitation. The extent, nature and cost of provision varies dramatically around the country with some services developing in a haphazard way with no core funding and relying on charitable donations and time ‘borrowed' from various hospital departments. The cost of cardiac rehabilitation varies enormously, from £17 to £2186 per patient, despite it being highly cost effective at around £550 per patient. There are also marked inequalities in the way people access the services that are available. Women, minority ethnic groups, the elderly and people with more severe CHD are all under-represented among users of rehabilitation services. Furthermore, in many parts of the country those that are ready to start a rehabilitation programme may have to wait for several weeks, thereby delaying their return to normal life.

Benefits

The potential benefits of robustly commissioning an effective comprehensive cardiac rehabilitation service include:

• greater survival for people with CHD who participate in comprehensive cardiac rehabilitation
• improving exercise tolerance and quality of life for people with mild to moderate heart failure
• reducing unplanned hospital admissions
• increasing choice for patients by offering hospital, home and/or community based rehabilitation programmes
• improving clinical outcomes through enabling people to become active self managers of their condition
• providing efficient clinical management at all four phases of the patient journey as recommended in ‘National service framework for coronary heart disease - modern standards and service models. Chapter 7: Cardiac rehabilitation'
• reducing inequalities and improving access for those groups less likely to access cardiac rehabilitation services, including people from black and minority ethnic groups, women, people from rural communities and people with mental and physical health comorbidities
• better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

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'
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a cardiac rehabilitation service include:

• ‘National service framework for coronary heart disease - modern standards and service models'. See chapter 2, ‘Preventing coronary heart disease in high risk patients', and chapter 7, ‘Cardiac rehabilitation'.
• The ‘Care closer to home' initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• ‘Commissioning framework for health and well-being'.
• ‘World class commissioning'.
• ‘The NHS in England: The operating framework for 2009/10'.
• Considering the impact of patient choice.
• The ‘Expert patients programme'.
• ‘A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services'.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with Standards for better health.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.