cardiac rehabilitation - national priority projects: lessons and learning one year on

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DIAGNOSTICSHeart Improvement

Cardiac Rehabilitation -National Priority ProjectsLessons and learning one year on...

STROKE

NHSNHS Improvement

October 2009

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 time scale for the projects varies, with some projects still in the initial

stages. Key learning from the project is available in brief in the introduction

to this document and in more detail in each of the project summaries.

Project summaries

Project summaries include issues to be addressed, baseline position, actions

taken, key learning and results to date from the 11 projects participating in

this work.

Contact details are included to provide additional information with regular

updates available on the website at www.improvement.nhs.uk/heart/rehab

Cardiac Rehabilitation

3Cardiac Rehabilitation - National Priority Projects

ContentsForeword

Introduction

Key Learning

Quality, Innovation, Productivity and Prevention

Project Summaries

Commissioning an equitable service across the countyDerbyshire County PCT

A sector wide approach to cardiac rehabilitation in South West LondonSouth West London Cardiac and Stroke Network

Rehabilitation triage assessmentNorth Lincolnshire and Goole NHS Trust

Planning cardiac rehabilitation commissioningDorset Cardiac and Stroke Network

Modernising a cardiac rehabilitation serviceNHS North of Tyne, North of England Cardiovascular Network

A redesigned service for North StaffordshireShropshire and Staffordshire Heart and Stroke Network

Improving access for Surrey patientsSurrey Heart and Stroke Network

Audit on the uptake of phase three cardiac rehabilitationBlack Country Cardiovascular Network

Referral to cardiac rehabilitation for PPCI patientsNorth West London Cardiac and Stroke Network

Vocational rehabilitation projectNorth West London Cardiac and Stroke Network

Cardiac rehabilitation across the PeninsulaPeninsula Heart and Stroke Network

Project Team

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www.improvement.nhs.uk/heart

4 Cardiac Rehabilitation - National Priority Projects


ForewordDuring this time of imminent financial constraint and commissioningpressures the national priority projects for cardiac rehabilitation (CR) havecreated a real sense of optimism within the clinical teams and have led tosignificant positive change which will become evident over the comingyears. NHS Improvement - Heart has taken positive action towardsensuring that lessons learnt in one work stream become the buildingblocks for other teams. This critical mass approach is key to achievingthe greatest impact in the shortest possible time which, for CR, isimportant because the challenge ahead is huge! Recent National Audit

of Cardiac Rehabilitation (NACR) figures show that uptake remains low (mean 38%) and that averagetrends in uptake did not change in 2007-2008. The NACR report and the network survey of CRhighlighted 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 totackle the problem, for example service redesign, innovations in commissioning and leadershipdevelopment, which we all know are important issues and challenges facing practitioners and serviceproviders.

The national priority projects for CR are the test bed for tariff debate and collectively we are makinga real contribution to shaping the future national tariffs for CR. One of the lessons, so far, is thattariff doesn’t bring new money but what is does is give commissioners and providers a clearframework for what CR costs. What we have learnt, through the CR projects, is that servicespecification is the key to commissioning best practice CR. NHS Improvement - Heart is primed toproduce meaningful support structures to help commissioners and providers achieve this is their ownlocalities.

It is less than one year since the CR national projects started yet we already have some clear successstories from individual projects and we see similar promise as the present projects roll out. The CRprojects are fully inclusive and thrive on close liaison with local commissioners, cardiologists, CRpractitioners and cardiac networks all of whom are committed to innovations aimed at enhancingreferral to CR and reducing inequalities in access over the next 12 months. The CR project team aretasked with making sure that the best possible outcomes prevail and that success is shared withothers.

My role as national clinical lead has been made possible and strengthened by close partnership withNHS Improvement - Heart and particularly Linda Binder and Dr Jane Flint both of whom have theskills and motivation to take the battle to where it counts. We look forward to even greater successover the next few years as we enable one of the most strongly supported clinical interventions, thatbrings substantial benefits to patients, to become a reality for those that require it.

Professor Patrick DohertyNational Clinical Lead for Cardiac Rehabilitation to NHS Improvement



The cardiovascular networks always promised to be effective healthcommunities, across which sharing good practice and ultimatelyredesigning ideal care pathways for patients, including cardiacrehabilitation could be made. Commissioning against commitment to keydefined outcomes is important. Although only a minority of networkshas so far worked with the national team on priority projects, thesenetworks already show an appreciation of both achievements ofprogrammes, and most importantly, the challenges faced across theirrespective 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

Foreword



IntroductionThe National PriorityProject for CardiacRehabilitation startedin September 2008following applicationsby cardiacnetworks and NHSorganisations and astringent reviewprocess. Nine projectswere chosen – some

of which had several strands of work and otherswhich were pulling together different sites into onemain project.

The overall aim of the national project was toincrease the access to, equity of provision anduptake of CR services for heart attack, angioplastyand CABG patients, piloting implementation of theNICE Recommendations on Cardiac Rehabilitation -as outlined in the NICE Clinical Guidelines CG48 onMI: Secondary Prevention and utilising the NICECommissioning Guide on Cardiac Rehabilitation asa resource to support improved commissioning.

We were particularly interested in receivingapplications where the focus would be on:

• Identification and active engagement of eligibleCR participants using a systematic and structuredapproach

• Development of mixed models of provisiontailored to meet the needs of individual patients

• Relevant rehabilitation for groups less likely toaccess the service such as women or ethnicminorities

• Development of exercise components designedto meet the needs of older people or those withsignificant co-morbidities

• Joint agreement, planning and commissioning ofservices across hospital trust, GP practice, PCTand social/leisure services and at network widelevel

• Exploration of the feasibility of a genericrehabilitation model encompassing other diseasemodalities.

We were also keen to ensure that the componentsindicated below were addressed:

• Reducing inequalities• Addressing diversity• Increasing access to and information about CR

services• Engaging patients/carers/families in planning

services• Workforce and multi-disciplinary team

approaches.

To share the learning a series of two monthlymeetings were initiated attended by projectmanagers and their teams. Led by the nationalproject leads for cardiac rehabilitation at NHSImprovement, (Linda Binder, National ImprovementLead, Patrick Doherty, National Clinical Lead andsupported by Dr Jane Flint, National ClinicalAdvisor) these meetings proved a very successfulmethod of providing peer support. Learning fromother projects and about national issues, such aswork around tariff negotiations, has provedinvaluable to progressing individual projects withinthe national initiative.

One year into this three year national project, theproject sites are keen to share their outputs todate. These range from projects whose workaround commissioning (and with commissioners)has led them to develop a service specification -and in one instance set up a tendering process -to others where the pathway has been examined,renegotiated or been subject to demand andcapacity work within the service in order increasethe numbers and types of patients accessingrehabilitation.

The quantifiable benefits are outlined within theprojects and summarised in terms of key learningand QIPP outcomes. Further detail on these pointsis contained in the project summaries that follow.

Linda BinderNational Improvement Lead,NHS Improvement



Outlined below are some of the key learningidentified by the projects after just one year:

• Ensure supportive and strong clinicalleadership/engagement to champion theapproach, aid decision making and manageclinical expectations of the group

• Ensure the right people are working on yourproject and that you are engaging with the rightstakeholders from the outset

• Understand baseline activity of existing serviceprovision and ensure there is robust data - crucialto help identify inequalities and to monitorprogress of work

• Build analyst time into your project and makesure your finance team are also on board ifnecessary

• 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 andgenerate cost savings into your business case

• Consider the implications of going out to tenderand whether you will need to buy in externalconsultancy

• 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.

Key Learning



Quality, Innovation, Productivityand Prevention (QIPP)Outlined below are some of the QIPP benefitsidentified by the projects after just one year:

QUALITY

Safety• Centralised referral and patient tracking• Standardised protocols and procedures assessed

against evidence base• Risk stratification form• Criteria for shuttle testing patients• Governance standards developed with

metrics system• Skills competency assessment.

Effectiveness• New community and home based programme

for IHD• 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 serviceswhich meet patient needs.

INNOVATION

• Rehab led follow up• Looking at ways to include health checks• Drug therapy reviews• Task group acting to coordinate all quality

initiatives.

PRODUCTIVITY

• Increased number of patients accessing rehab• Reduced hand offs – integrated team with fewer

referral steps• Using and scheduling staff more effectively• Rehab led follow up – reduces the need for

outpatient attendance• Ensuring availability of MDT staff to

increase flow.

Proj

ect

Sum

mar

ies




Synopsis

Our challenge was to commission an effective,consistent and equitable cardiac rehabilitationservice across Derbyshire PCT by providing carecloser to patient’s homes and offering them amenu based service.

Over the course of two years we have aimed toidentify our baseline, develop a new model ofservice, ‘build’ a business case to secure funding,develop a service specification and procure theservice through a formal tendering process.

To date we have secured funding for the serviceand we are preparing to go out to tender beforethe end of 2009.

Background

The merger of six PCTs to form DerbyshireCounty Primary Care Trust (PCT) in 2006 led to adiffering level of provision of cardiacrehabilitation across the health community. Thelarge and diverse PCT has meant that patientshave been receiving rehabilitation from a varietyof service providers, many of which are locatedoutside of the PCT boundary. In 2007 a strategywas developed to identify the main issues facingcardiac rehabilitation services in Derbyshire,these are summarised below:

• Inequitable service. There is no consistentcardiac rehabilitation pathway acrossDerbyshire; therefore it is the geographicallocation of the patient that has determinedthe service received. The lack of a coordinatedapproach towards rehabilitation has meantthat programmes have not been distributedequitably in response to need; analysis hasshown that in the area with the highestprevalence patients were expected to travelsome of the largest distances to access aprogramme.

• Poor uptake. In some areas of the county itwas identified that there was a poor uptakerate. This was most notable in the BolsoverSpearhead area, where it was calculated thatas little as 16% of eligible patients were takingup cardiac rehabilitation. Contributing factorsare thought to be; distance to hospital basedprogrammes, associated parking charges andlack of choice of programmes available.

• No clear funding streams. Historically themajority of budgets have been tied up withinacute trust contracts. The lack of clear fundingstreams has meant that the cost of cardiacrehabilitation varies across the PCT and doesnot always represent good value for money.

• Lack of data to support cardiacrehabilitation. Not all of the service providersthat provide cardiac rehabilitation forDerbyshire patients use the NACR databaseand data varies enormously in terms of quality.The lack of a centralised system has meantthat data has not been able to be used toensure everyone eligible for cardiacrehabilitation has been offered it.

Current service provision for peopleresident in Derbyshire

• The stars in blue are community services thatprovide cardiac rehabilitation phase 3 only

• The green stars show the number of acuteprovider services that our patients inDerbyshire can access. Some of these alsoprovide a phase 3 programme. However,apart from the two main provider trusts inthe county many patients find the distanceto travel back to the other provider trustschallenging and therefore for our patientsthere is little uptake of the phase 3provision.

Commissioning an equitable service across the countyDerbyshire County PCT



What we did

The aim of the projectThe aim of the project is to commission aneffective, consistent and equitable cardiacrehabilitation service across Derbyshire in orderto optimise uptake and maximise healthoutcomes for the population.

Planned outcomes for the project

• Increased access: the service is movingtowards a menu based model wherebypatients will be able to choose a service thatmeets their individual need. This will optimiseuptake and provide more patient centred care.The planned increase in community basedprovision will reduce the distances peoplecurrently are required to travel and as a resultincrease access. The referral criteria will includeangina and heart failure patients, two groupswho are not consistently offered cardiacrehabilitation at present.

• Reduction in health inequalities: serviceprovision will be planned in accordance withthe greatest health need, taking into accountdisease prevalence, deprivation and access. Amenu based service will ensure that people arenot excluded from cardiac rehabilitationbecause they choose not to attend a formal,group programme.

• Increased links with primary care and longterm maintenance options: communitybased services will support the development ofstronger links with the communities thatpatients live in. The new pathway will seek toensure a seamless transfer of patients intolong term healthy lifestyle options as well asmaking sure that all patients receive structuredfollow up by primary care.

• Increased effectiveness: the service will becommissioned with a focus on outcomes. Thiswill ensure delivery of the health benefits thatcardiac rehabilitation can provide.

• Increased financial effectiveness: the newpathway will seek to standardise the cost ofcardiac rehabilitation across Derbyshire so thatvalue for money can be achieved. It isanticipated that by commissioning for bothactivity and health outcomes service providerswill be driven to deliver quality care andefficiencies.

The steps taken to achieve the aim and plannedoutcomes of the project are summarised below:

a.Baseline measurementWork commenced to understand our currentlevels of activity and financial commitment.This was challenging due to the number ofproviders, complicated financial arrangementsand variation in data collection.

b.Development of a new cardiacrehabilitation pathway for DerbyshireA work group consisting of clinicians from themajor providers, commissioners, public healthspecialists and a patient representative cametogether to develop a new pathway forDerbyshire County PCT residents. A clinicallead who works across both primary andsecondary care was appointed and her rolewas critical in leading the development. Someof the actions the group took to facilitate thedevelopment of the pathway included:• Process mapping with clinicians and patients• Brainstorming what an ideal pathway should

look like against national evidence and bestpractice

• A site trip to a cardiac rehabilitation servicereporting high uptake and good outcomes

• A patient representative working with usthroughout the project.

c. Identification of additional fundingA business case was developed bycommissioners outlining the key issues andrisks with the current service and identifyingpotential benefits and savings to the PCT.

d.Development of a service specificationAdditional funding was secured through thePCTs Local Operating Plan for 2009-10 andwork commenced to translate the pathwayinto a service specification and define keyperformance outcomes.

e.Commencement of a procurement processto drive improvementDue to the number of existing providers, thepotential value of the contract and the level ofservice redesign it was decided that a formalprocurement process would be the bestmethod for securing the best health outcomesand value for money service.

The biggest issue/challenge

Defining the baseline was crucial to identifyingthe amount of activity to be commissioned andto understand the local picture. It provedextremely difficult to calculate the current spendon cardiac rehabilitation services because of thelack of clear funding streams. In one case,investigation by one of the acute trust serviceproviders highlighted the fact they had not beencharging the PCT at all for the activity. Gettingreliable and accurate data on the number ofpatients who would be eligible for cardiacrehabilitation and understanding which patientswere already accessing the different pathwayswas also a complicated process. Both tasks tooklonger than expected and required significantfinance and analyst input.

The impact to date

This project is about planning for andcommissioning a new cardiac rehabilitationservice. To date the key success factors include:

• Development of a new pathway• Securing additional funding in order to

implement the new pathway• Development of a service specification.

The service specification will ensure that theimpact of the service, once commissioned, willbe able to be measured by commissioners on aregular basis. This will include:

• Activity – up take rate against national targets,decliner rate, completion rates, referral rates toother services

• Health outcomes – patients will be expected toachieve a certain number of health outcomesincluding, treatment outcomes, clinicaloutcomes and patient centred outcomes

• Quality outcomes such as accessibility of theservice, patient and carer satisfaction,compliance with national standards andwaiting times etc.

Barriers, challenges, and lessons

Key learning points from Derbyshire CountyPCT project:



a.Ensure the right people are working on yourproject and that you are engaging with theright stakeholders from the outset of theproject. These may include cardiacrehabilitation clinicians, public health, GPs,finance, HR, information, leisure services,support groups, cardiology etc.

b.Understand what is currently happening inyour PCT in terms of baseline activity andunderstand how it is being paid for. Buildanalyst time into your project and make sureyour finance team are also on board to assist.

c. Consider early the possibility of going out totender and communicate this to yourstakeholders.

d.Ensure you have strong clinical leadership butconsider the implications of going out totender and whether you will need to buy inexternal consultancy.

e.Build a business case and make sure youpromote the ability of cardiac rehabilitation toreduce admissions and length of stay andproduce cost savings.

f. Learn from other trusts that are doing well, asite visit is often a good way of doing this.

g.Spend time defining your key performanceindicators. Allow potential providers to beinnovative in their response to your servicespecification.

h.Dedicated project management time.

Next steps

The new pathway for cardiac rehabilitation isexpected to be commissioned by the PCT via aformal tendering exercise within this financialyear. The successful provider or providers willthen work with the PCT to implement the newpathway through a phased approach over thefollowing six months.

Contact details

Ciara Scarff, Long Term ConditionsCommissioning ManagerEmail: [email protected]: 0115 9316159

Janet Whitehead, Public Health SpecialistEmail:[email protected]: 01629 817931 x2316

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A sector wide approach to cardiacrehabilitation in South West LondonSouth West London Cardiac and Stroke Network

Synopsis

What 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 andstarting to pilot initiatives during the first year,with ongoing evaluation and roll-out ofsuccessful initiatives running into the secondand third years of the project.

What was your solution(s) or approachto this?Our approach has been two-pronged. Newinitiatives are being trialled using a PDSA cyclebased approach (plan, pilot, review, androll-out). In addition, the network team agreedto support service redesign work that hadalready commenced, ensuring that the agreedpathway was firmly embedded in this work.

What worked/ didn’t work to date?So far, the approach we have taken to pilotingand rolling out initiatives has been successful.We have had been able to implement initiativesthat have worked well in other areas, using thelearning from pilot sites to support this. We havealso trialled some initiatives in one or two sites(such as ward staff delivering phase one) andfound these to be less successful and thereforethese have not been picked up post-pilot.

Involvement in the national priority project hasbeen very valuable to stay abreast of what’sgoing on both at a national level and in otherorganisations from across the country.

Work on the commissioning and tariffworkstream has been slow, partly due to thelack of information available about the tariff.However, a pan London event focusing on thecommissioning of cardiac rehab services in May

was successful, with a lot of positive feedbackreceived and work is now progressing to agree apan London set of outcomes for cardiac rehab.

What would you do differently?The initial focus of the project was on theincoming phase one tariff as programmes in thesector were keen to look at implications of this.In retrospect, the initial work should havefocused on ensuring all teams had robust datato inform commissioners and to support shadowmodelling of tariff once agreed.

Also, tighter project planning in the early phasesfor elements which are reliant on others todeliver would have enabled us to be clearerabout roles and responsibilities and manage theprocess more firmly.

Background

The idea for this project arose from the findingsof a retrospective audit of cardiac rehabprogrammes in South West London, and anassessment of these programmes against theNSF and the BACR standards (appendix 4).These indicated that there was a range of rehabprovision across the sector, with inequalities inprovision for different groups. In addition,cardiac rehab services across the country arestriving to provide a ‘menu’ of rehab options, topromote onward referral to existing preventionservices, and to increase the range of settings inwhich rehab is provided. The aim of this is toprovide services which are more flexible and canbe tailored to fit patient needs more easily,thereby increasing uptake.



Research findings and local patient feedbackindicate that patients feel most vulnerable inthe early post discharge phase and this is mostevident in patients who spend short periods oftime in hospital (such as primary angioplastypatients who have an average length of stayof three days). The network task grouptherefore developed a high level pathway forimplementation (see appendix 1). The keyfeatures of this pathway are the emphasis onthe early post discharge phase, the range ofoptions available, the range of settings available,and the links with existing prevention services.The aims and anticipated benefits of the projectare outlined in appendix 2.

What we did

The baseline data for this project was takenfrom the retrospective audit and baselineassessment conducted in 2007. Workstreamswere developed in conjunction with the taskgroup, and have evolved as the project has goneon to reflect changes locally (i.e. within existingservices) and nationally (i.e. tariff development).Pilot sites for initiatives were selected based onenthusiasm of programme leads, fit withongoing work (redesign work and otherinitiatives currently underway) and anassessment of need (e.g. drug therapy reviewpilots will be selected based on audit results).

Initiatives are being implemented through apilot, evaluate and roll-out approach andthrough integration with service developmentand service redesign work already underway.It is anticipated that the pathway will beembedded throughout the sector onceworkstreams have been evaluated and thelearning from these shared amongst theorganisations in our sector. The project leadsplan to drive and embed ongoing serviceimprovements through supporting robustcommissioning of CR services in our sector.

Metrics have been developed for the cardiacrehab workstreams of both South Londonnetwork workstreams, which will be reviewedfor sign off in September 2009. These havebeen aligned with the project measures toenable ongoing measurement of impact andmonitoring to ensure sustainability (seeappendix 3 for the draft dashboard).

This project has taken a sector wide approachwhich has been beneficial in working towardsreducing inequalities and supporting programmeleads to progress service improvement work.Pan London work has also commenced todevelop a joined up approach to the key issuesfor rehab services, promote networking, tosupport joined up working between providersin different sectors, and to ensure somestandardisation in the commissioning ofCR services.

The aims of this project were:• To improve access to cardiac rehab for all

groups of cardiac patients• To reduce inequalities throughout the sector• To improve uptake by providing a sector-wide

service that is responsive to the needs ofpatients and clinicians

• To ensure providers and commissioners areworking together to plan, develop andcommission appropriate services for localpopulations.

The key high level outcome of this project wasthat all communities in the sector have highquality, robustly commissioned CR servicesproviding a range of activities in a range ofsettings that can be equitably accessed by allgroups of patients that can benefit. The aimsand anticipated benefits of the project areoutlined in appendix 2.




The network task group has a quality assurancerole for rehab programmes in the sector and thishas led to unplanned involvement inprogrammes undergoing changes which havedestabilised other local programmes. However,this has clear links to the project as ensuresequity of provision across the sector.

The quality assurance role has been essential tothe delivery of the project as services indevelopment and those undergoing significantchange are taken to the network task group toenable them the group to have oversight of CRservices in our sector, allowing them to assessequity of provision. This role was signed off bychief executives in the sector and enables ourtask group (professionally and organisationallyrepresentative) to input to local decision makingfrom a clinical perspective.

Involvement of the project leads in qualityassurance activities has been particularly timeconsuming and has adversely affected timescales for the project as several initiatives havehad to be placed on hold while issues areresolved. This has, however, been essential toachieving the project objectives and althoughsome of this work has been unplanned, andsomething we were unable to anticipate, it ishas been important in helping us to achieve theend project goals.

The impact to date

The scope of this project means that manyinitiatives are still at the planning or earlyimplementation stage. Preparatory work hasincluded:

• Business case development• Project planning for drug therapy review

(including South London audit) and rehab ledfollow up (pilots to commence later this year)

• Skills competency assessment tooldevelopment using Skills for Health CHDcompetencies (used with two teams to identifytraining needs in relation to the new pathwayand has been shared with national priorityproject colleagues).

Work to reduce inequalities in access to CR fordifferent patient groups is progressing well inmany areas, including the development of anumber of new programmes.

• A successful ICD CR pilot has enabled sectorwide roll out to commence

• A new community IHD CR programme hascommenced targeted specifically at hard toreach populations

• A new community programme incorporatingheart failure rehab has been developed withnetwork support (recruitment almostcomplete, programme to commence autumn2009)

• A local PCT has agreement to develop a stableangina community CR programme, supportedby discovery interviews conducted by networkleads.

In addition, existing programmes have begun tobroaden their inclusion criteria, enabling morepatients who can benefits from cardiac rehab toaccess services.

The scope of this project means that lead in timefor delivery is much longer than for projects witha more discrete focus, however this means thatthe impact and benefits of this work oncerealised will be much broader. It is anticipatedthat this project will impact on patient outcomes(such as quality of life, knowledge of theircondition, risk factor modification, etc as well asmortality and morbidity), process of careoutcomes, resource utilisation outcomes (such asonward referral to services such as smokingcessation) and cost outcomes. It is envisagedthat the impact of the project of some of theseoutcome measures may not be noticeable in theshort term but these will be reviewed one yearafter project work has finished.

The impact of this project is being measuredthrough the South London cardiac rehabworkstreams dashboard. This measures theimpact at a high level as the scope of the projectis broad (sector wide), with the recommendationthat local / workstream level data be measuredand monitored locally through NACR. Forexample, the dashboard monitors which groupsof patients are able to access cardiac rehab in



each borough, with a recommendation thatprogrammes use NACR to monitor activity datafor different patient groups.


What worked and what didn’t work; whatyou would do differently/ the same;Pan London working has been very useful,enabling us to minimise duplication, developcontacts and network effectively, and providethe London networks with an approach totackling inequalities in cardiac rehab provisionmore easily. A pan London cardiac rehabconference was successful, with positivefeedback from delegates who felt that thisimproved their knowledge of the commissioningprocess. Delegates also felt that developing apan London set of outcomes for cardiacrehabilitation was an important piece of workand that networks were in a position to supportthis.

An initiative to pilot role changes for phases oneand two was not successful. The aim of this wasto have ward nurses provide phase one input,thereby freeing up the time of the rehab teamto focus on a delivering a more comprehensivephase two service. This was unsuccessful due tothe lack of time for the ward nurses to provide afull phase one service. In addition, it becameevident that this did not fit well with incomingtariff once the tariff costs were confirmed. Inretrospect, it would have been better to assessmore closely staff capacity on the wards, to waituntil tariff information was clearer, and to run askills competency assessment with key staffbefore commencing this initiative.

This project has taken a broad approach topatient involvement and this has been veryhelpful in informing the project direction todate. A decision was made not to have a patientrepresentative on the task group but to have aliaison member from network patient group andto have a range of mechanisms for patientinvolvement tailored as appropriate. The aim ofthis was to gain a broader picture of the patientand carer perspective of rehab services andpathways, and to avoid tokenisticrepresentation. Appendix 4 outlines thisapproach.

Key challenges/ barriers toimplementation/ risks to deliveryand how you overcame themA major challenge for this project has been thelack of robust data available to us. Better datawould have been immensely helpful to supportcommissioning discussions. A lack ofunderstanding by individual programmesregarding their funding streams has been aparticular hurdle as this has had to be clarifiedwhilst trying to avoid leaving unfundedprogrammes in a vulnerable position. The panLondon work on developing outcomes forcardiac rehab has also been hindered due to thelack of robust data and the approach altered toallow for a ‘shadow period’ to help identifyrealistic parameters for outcome measures.

Key learning/sharing points

Leadership and planningOur clinical lead has been very supportive of thisproject and has been involved in project decisionmaking and championing the approach. Wehave a cardiology lead on our group who hashelped us with applying our quality assurancerole to programme changes in the sector.

Joined up working with other networkworkstreams has been very productive. Forexample, our patient diaries project has runacross the revascularisation and rehabworkstreams, with the diaries being completedfrom pre-assessment, through the inpatient stayand throughout the rehab phase, giving us a fullpicture of the pathway and not just the rehabelement.

Clinical engagementClinical engagement has been essential indriving this project. Involvement of local cardiacrehab clinicians in the development of thepathway prior to the project commenceddefinitely helped to achieve early buy-in. This hasalso ensured that programmes in the sector hadearly consensus on the project goal/end point.In addition, the group has an enthusiastic andsupportive clinical, and is organisationally andprofessionally representative, both factors whichhave been essential to decision making andimplementation.



Information transferOur task group meets every six-eight weeksand this has been the forum for project issuesto be discussed. We have found interimcommunication (email / phone) as well as beingavailable for ad hoc discussion has helpedresolve issues quickly. Within the network teamwe have used our NPP monthly reports and theNHS Improvement System to communicateproject progress.

For initiatives that have multiple leads andmultiple organisations involved we have foundit really useful to have a set of communicationtools that clearly articulate the background,approach and plan for the work. For example,the drug therapy reviews pilot is being set up bynetwork leads from South East and South WestLondon along with the pharmacy lead thatworks across these networks. Early in the projectwe produced a PID and a briefing paper thathave been used for meetings with network taskgroups, potential pilot sites, and industry links,ensuring consistency of communication andminimising duplication of effort.

Provision in community settingsThere are a number of community cardiac rehabservices in our sector now, with several more indevelopment. An important learning point for ushas been around ensuring that these are joinedup with other programmes (e.g. hospital basedprogramme and existing prevention schemes)right from the beginning. Wherever possibleteams should be in a position to cross-cover tomaintain flexibility and consistency in provision.For small teams these links can also help preventprofessionals feeling isolated by promotingshared learning and peer support. In boroughswith multiple CR providers it is also veryimportant to ensure there is clarity and goodcommunication about patient choice and referralroutes. The project team are currently producinga strategic vision paper to inform commissionersat hub level regarding cardiac rehab provision.

Work to address health inequalitiesWe have found that having a good baseline ofexisting service provision and robust data iscrucial to help identify inequalities and tomonitoring progress of work aimed atreducing these.

Next steps

We will continue with the approach outlinedpreviously, ensuring that this is supported byrobust evaluation processes and that thelearning from each initiative is sharedappropriately. We plan to monitor progress at asector wide level through the South Londondashboard, which will be signed off in autumn2009, along with a set of governancerequirements. A South London leads group willbe established to support this and to take astrategic overview and to help align theworkstreams.

We will continue to review progress in anongoing manner with pilot and roll out sites tohelp embed and sustain this work. We anticipatethe task group as having a key role in sustainingchanges and rolling out good practice.

Contact details

Alice Jenner,Project Manager,South West London Cardiac and Stroke NetworkEmail: [email protected]: 020 8725 0956

Michelle Bull,Senior Project Manager,South West London Cardiac and Stroke NetworkEmail: [email protected]: 020 8725 1192

NB: Appendices 1-4 are available fromthe NHS Improvement website at:www.improvement.nhs.uk/heart/rehabprojectsummaries



Rehabilitation triage assessmentNorth Lincolnshire and Goole Hospitals NHS Trust

Synopsis

What was the problem, challenge or issueyou were trying to resolve?We noted that patients were not getting timelyaccess to their cardiac rehabilitation. Thisappears to have resulted from the fact that weas nurses have stopped attending a secondaryprevention clinic run by the medical team; andalso as patients are transferred to other hospitalsfor intervention they are not always referredback in a timely manner.

What were you trying to achieve inthe time available?We were trying to ensure that patients receivetimely and appropriate access through triage tophase three cardiac rehabilitation. This willreduce inequalities in accessing the service andso improve patient’s quality of life. To be able togive patients a date for pre-assessment inadvanced without having to be added to awaiting list.

What was your solution(s) or approachto this?• We intend to use the national audit for

cardiac rehabilitation database as a backupfor those patient’s who have had a procedurein another hospital

• We have changed our paperwork• We have developed a flow chart to ensure

that we are all working to the same guidelinesand standards so that all patients have equalaccess at the appropriate time.

What worked/didn’t work to date?We attempted in spring 2009 to undertake apiece of demand and capacity work which wassupported by our cardiac network. However, dueto staffing issues within the department wewere unable to complete this piece of worksuccessfully. Since June 2009 these issues havebeen resolved. We have not attempted torecreate the original piece of demand andcapacity work as our service configuration haschanged.

What would you do differently?Capacity and demand work would have beenmanaged differently, we feel that this was toolarge a piece of work and should have been splitinto two smaller pieces. We have now broken it

into two sections one is looking at currentdemand and one looking at attendance againstattendance.

Background

The priority project initiative is to triageparticipants into appropriate cardiacrehabilitation, using a structured pre-assessmentand follow up evaluation. Prior to the projectpatients were put on a waiting list for exercise.The waiting list dates back to 2001, we havemade several attempts to try to address waitingtimes, but have been unsuccessful. However,during this time the service has expanded toinclude angioplasty and heart failure patients,with a year on year increase in service users. Dueto the time on the waiting list we find that somepatients have declined to undertake exercise bythe time we are able to bring them into theprogramme, either because they have startedexercising on their own, or they are back atwork and do not feel that they would benefitfrom an exercise programme. We have increasedour capacity for exercise by now providingcommunity based exercise programmes and ahome based programme from a British HeartFoundation/Big Lottery grant. We initiallythought that this would help us to address theseissues in people having to wait to start theexercise programme; however, we have foundthat we now have a longer wait to access theprogrammes. Our team felt the national priorityproject initiative would give us the requiredframework to look at our service and help us tohighlight the relevant issues in order for us tomake the appropriate changes.

What we did

The aims and objectives of our project are totriage participants into appropriate cardiacrehabilitation, using a structured pre-assessmentand follow up evaluation. This will benefit thepatients by enabling them to have timely andappropriate access through triage to physicalactivity; improved quality of life for individuals, itwill provide an ideal opportunity to signpostindividuals to other aspects of the cardiacrehabilitation service, and provide an opportunityto re-enforce key health care messages.



The expected outcome measures are:• An improved quality of life measured via

hospital anxiety and depression (HAD) score• A reduction in service utilisation by this group

of individuals, (reduction in readmission, outpatient follow up and consultations)

• Flexibility of waiting time to attend the cardiacrehabilitation programme to meet theindividuals needs

• Improved physical function by an appropriatetool

• A clear management plan for each individualwhich will be informed by discussion with thepatient and their carers.

We have added some health outcomes into ourguidelines for referral and entry into the cardiacrehabilitation programme, for those whocomplete 70% of the phase three cardiacrehabilitation exercise programme there shouldbe evidence of benefit in two out of four of:• Improvement in functional capacity test

by 10%• Improvement in HAD score by four points• A measure of continued exercise either by

referral to phase four sessions or individualprogrammes

• Attainment of more than one risk factortreatment goal (eg stopping smoking,reducing cholesterol, reduction in bloodpressure).

Process mappingFirstly we process mapped our service with thehelp from the cardiac network. The process maphighlighted the fact that we needed toundertake some demand and capacity work, aswe were not able to highlight where the barrierswere regarding the patients having timely accessto their cardiac rehabilitation. It also highlightedthe issues we have in relation to those of ourpatients who have a complex journey, whichprevents us from identifying the point at whichthey are suitable to undertake the exerciseprogramme. This is often due to patients beingtransferred to our tertiary centre for furtherinvestigations and procedures, and they are notalways 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).

Demand and capacityWe have now revised the demand and capacitywork; as this was not as successful as we hadoriginally hoped, due to staffing issues, and theneed to change our service configuration. Wehave changed our registers for the programmes,so that we are continually monitoringdemand/capacity/uptake and unused capacityon a weekly basis.

Allocation of pre-assessment appointmentWe have now allocated designated slots for pre-assessments, as we felt that with offering sevendifferent exercise programmes, the managementof allocating these patients was left to oneperson which often became overwhelming withother work commitments. At pre-assessment weare able to discuss with the patient and theirrelative what their needs are, and make anappropriate plan to meet their needs. We do thisthrough an assessment of their lifestyle; recordtheir blood pressure and pulse; undertake afunctional capacity test; all patients complete aNACR questionnaire, and a risk assessment iscarried out using the BACR risk assessment tool.Once we have all this information we discusswith the patient and relative where is the mostappropriate place for them to exercise.

Individual programme managerWe now have split up the management of theexercise programmes, and pre-assessmentallocation, so that each member of the team hasa specific programme that they manage. Theteam then meets on a weekly basis and eachprogram leader updates the rest of the team ontheir specific programme. We also discuss eachpatient who has been highlighted as fit andinterested to undertake the exercise componentof cardiac rehabilitation. If we notice at thesemeetings that there is a wait starting to developat one particular programme, we will discuss ifthere is any capacity elsewhere and offer thepatients an alternative site. Each programmeleader will then make an appointment for thepatients that are relevant to their programme inorder for the patient to be assessed fully.




Challenges remain regarding identification ofpatients who are ready to exercise but whoexperience a complex patient journey. We feelthat one reason for this is because our maintertiary centre has a high patient workload but alimited cardiac rehabilitation service. The referralof our patients back into our service is not seenas a priority by their nursing teams.

One issue identified through the project was ourinability to quantify demand against capacity.As already identified we were unable tosuccessfully complete this piece of work. Wehave not attempted to recreate the originalpiece of demand and capacity work but havechanged the focus to monitor attendanceagainst capacity and unutilised capacity.

Work undertaken during the project hasidentified the programmes running with unusedcapacity. We were able to identify that this wasdue to our management of the existing patientpathway. The impact of our action/inactioncreated a waiting list and caused us to ‘fire fight’to reduce waiting times rather than having aclear long term strategy to promptly identifypatients who are ready to attend an exerciseprogramme.

Prior to the project one person managed all theexercise programmes. This created an issuewhen workload increased. The identification ofpatients suitable for exercise becameinconsistent, pre-assessment dates were notrequested in a timely manner and if patientscancelled their appointment we were notconsistently reallocating the appointment toanother individual.

The impact to date

We no longer have a waiting list for ourScunthorpe and community programmes. Allpatients are allocated a pre-assessment datewithin one week of being identified as beingsuitable for exercise.

The issues which created a waiting list at theGoole programme are almost resolved. Ourtarget is that by 31 October 2009 there will beno waiting list at the Goole programme.

The waiting list for the seated exerciseprogramme will remain as this group of patient’sability to exercise can be affected by non cardiacreasons causing the group to change at shortnotice. However to optimise attendance we havedeveloped a 10 week rota.

We are now able to consider the introduction ofa programme specifically for heart failurepatients. By managing our demand and capacitybetter will enable us to utilise our resourcesdifferently to enable us to offer our Heart Failurepatients a specific programme in the futurerather than including them in the gym with nonheart failure patients.

Working in partnership with local serviceproviders has enabled us to fast track patientsthrough Phase three exercise onto phase fourprogrammes when appropriate resulting inincreased capacity in the Phase threeprogrammes.

We are currently developing flow charts bywhich all team members can identify whichprogramme is appropriate for each patient. Theflow chart will identify a pathway for complexpatients to enable us to identify when they areready to attend an exercise programme.

Each programme has an identified programmecoordinator who manages and monitorsdemand, capacity, waiting times and attendanceon a weekly basis.

At our weekly team meeting each programmecoordinator updates the rest of the team ontheir programme. If a programme is notrunning at available capacity we discuss therelated issues and agree a strategy to preventcapacity wastage. (see appendix 6)

Barriers, challenges and Lessons

What worked/what didn’t workThe process mapping exercise plus demand andcapacity work has given us a betterunderstanding of patient flow through ourservice. The team can now see how ouraction/inaction impact on waiting times forpatients ready to access cardiac rehabilitation.

We have revised our demand and capacity workto reflect current practice. Staffing issues withinthe department, which are currently in theprocess of being resolved, resulted inreconfiguration and suspension of someprogrammes in spring 2009. Although the teamrecognize this was not ideal we felt it was betterto offer the majority of patients some ratherthan no rehabilitation.

Challenges/barriersA challenge for the future success of our projectis to ensure that when making changes to ourservice to meet the project aims and objectivesthat we do not create an alternative bottle neckin the patient journey.

Our cardiac rehabilitation team has been stablefor several years however there have been recentunavoidable changes within the team. Oneconsequence has been the need to re-evaluatethe 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

partnership with our local cardiac network andpartner agencies to work out a long termstrategy to address this challenge.

Key learning /sharing points• Understand your demand and capacity• Ensure service reconfiguration does not create

an alternative bottleneck• Build sustainability into your service• Multiagency partnerships can increase

flexibility within your service.

Next steps

• Our ability to assess health outcomes anddevelop a strategy for follow up evaluation hasbeen hampered by staffing issues within ourdepartment and the need to reconfigure ourdemand and capacity work

• Our team together with our local cardiacnetwork is developing a prompt and reliablereferral pathway for post intervention patientsdischarged from our tertiary centre

• We intend to commence collecting healthoutcome measure data

• The second year of the project will concentrateon these elements of our project.

Contact details

Louise BevingtonActing Lead Cardiac Specialist NurseCardiac Rehabilitation

Email: [email protected]: 01724 290093






Synopsis

What was the problem, challenge or issueyou were trying to resolve?To fully understand the current cardiacrehabilitation service across Dorset so thatall programmes are supported to reach theminimum BACR Standards and CoreComponents (2007).

What are you trying to achieve in the timeavailable?The project will take into account the NICECommissioning Guide for Cardiac Rehabilitation(2008) in terms of determining local servicelevels, developing a service specification andbuilding on mechanisms for quality assurance.

What was your solution(s) or approachto thisThe cardiac rehabilitation service across Dorsetwill jointly agree a minimum service specificationwhich will form a basis by which all futureservices will be commissioned to ensure equityfor all patients who require cardiac rehabilitationacross Dorset

What worked/did not work to date?The project has been well supported bycommissioners and clinician from primary andsecondary care. The cardiac lead nurses havealso shown commitment and enthusiasm fordriving the project forward and implementingchanges that have improved cardiacrehabilitation services. The national peer supportmeetings have been well attended by thenurses and by our patient representative.

What would you do differently?Have a clear project plan from the start, withtimeframes and specific roles andresponsibilities formulised. The initial bid and thefirst six months of the project was managed bytwo different project managers. Learning serviceimprovement methodologies has been valuableto drive the project.

Background

Pan-Dorset serves a population of 758,000 andthis project involves three Acute Trusts: RoyalBournemouth NHS Foundation Trust, PooleHospital NHS Foundation Trust and DorsetCounty NHS Foundation Trust. The three cardiacrehabilitation programmes vary in length,content and the place of delivery. Allprogrammes access cardiac rehabilitation phaseone and two in secondary care.

Dorset is a rural location and offers phase threeprogrammes in four community sites.Bournemouth offers phase three in secondarycare only and Poole offers phase three in bothsecondary care and in the community.

Cardiac rehabilitation across Dorset is offeredroutinely to only three of the many diagnosticgroups who might benefit. Such as those whoundergo cardiac surgery, have a heart attack,and those who have percutaneous coronaryIntervention. Patients with heart failure, angina,valve disease and have cardiac implantabledevices are not routinely offered cardiacrehabilitation.

What we did

We set up a Dorset wide cardiac rehabilitationsub-group to promote joint working and steerthe project. The sub-group members involved inthe project include clinicians, commissioners,local authority, cardiac network team andpatient and carer representatives.

The Dorset Cardiac Network embraces theprinciple that Patient and Public Involvement(PPI) should be central to service provision anddevelopment. The Dorset Cardiac Network hasproduced a paper detailing the PPI plans for thisproject (see appendix 7). In brief it includes howrepresentatives will be empowered andsupported in their role as members of theproject team and also describes how variousmethodologies will be employed throughout theduration of the project to ensure that the viewsof local patients and carers inform the work ofthe project team on an ongoing basis.

Planning cardiac rehabilitation commissioningDorset Cardiac and Stroke Network

The key aims of the project – using a phasedapproach is to:• To improve access for all groups of cardiac

patients• To increase uptake of cardiac rehabilitation• To minimise inequalities across Dorset• To meet the South West ambitions target

which says:

“By March 2011 at least 85% of peoplewith a heart attack, bypass surgery orcoronary angioplasty will receive cardiacrehabilitation.”

In order to fully understand the local cardiacrehabilitation services between September 2008– April 2009 an extensive audit and analysis ofthe cardiac rehabilitation programmes acrossDorset was benchmarked against the BritishAssociation for Cardiac Rehabilitation (BACR)Standards and Core Components (2007).

The key findings from the audit receivedcomments from members of the cardiacrehabilitation sub-group and recommendationshave been planned to address inequalitiesand aid service improvement.

Recommendations from the BACR Audit1. Patients should be offered choice of home,

community or hospital cardiac rehabilitationprogrammes. The delivery of cardiacrehabilitation should be predominately basedin the community, particularly for thosepatients with mild to moderate risk. Forpatients with more complex needs, referralto hospital based rehabilitation programmesshould be available. In both casesprogrammes should be arranged to maximisepatient choice with regard to day, time andvenue.

2. On completing the cardiac rehabilitationprogramme all patients should be providedwith information regarding existing voluntarygroups, networks, psychological support sothat patients can access for ongoing support.

3. On completion of the cardiac rehabilitationprogramme all patients should be providedwith a discharge management summaryexplaining diagnosis, recent blood pressure,cholesterol result, list of medications andrecommended medication optimisation planfor the GP to follow.

4. Links should be improved with localcommunity leisure services to support theprovision of suitable phase four exerciseprogrammes for cardiac patients in thecommunity.

The second step was to undertake an uptakeand access audit to identify the number ofpeople receiving cardiac rehabilitation and thereasons why people did not take up cardiacrehabilitation or complete the course. The twobaseline assessments will form the basis ofongoing work.

Each phase three cardiac rehabilitationprogramme across Dorset was asked to collectdata on patients who had a cardiac event duringthe sample period of 1 January - 31 March2009. The analysis started in August when allpatients in the sample group should havecompleted the programme. Full results of theaudit will be completed by the 30 Septemberand published on the NHS Improvementwebsite. Preliminary results are available(see appendix 7).

The biggest issue/challenge• Defining the South West ambition target was

a challenge and caused much debate – theteam were unsure if it meant 85% of patientsoffered cardiac rehabilitation or 85% shouldreceive phase three cardiac rehabilitation.

• There is no direct guidance that exists on whatproportion of a programme needs to becompleted to ensure efficacy. Comments fromPatrick Doherty National Clinical Lead by emailare helpful to aid discussion:

“If you are fortunate to run aprogramme twice weekly for eightweeks or more then you could use 80%because it will keep you within the 12sessions threshold (two sessions perweek for six weeks) which, via the NSFfor CHD and Joliffe et al's review, isconsidered the minimum a number ofsessions related to efficacy.





The difficulty comes when you have setgoals that require more time to achievesuch as smoking cessation and weightreduction. Equally if you have patientswith high levels depression/anxiety orthose with difficulties taking on boardsecondary risk management behavioursit is important to ensure that theyattend all sessions.

It is easier to make up for a drop inexercise sessions in the community butless so for the education sessions.Programmes should try and ensure thatall educational components are deliveredprior to discharge”.

Professor Patrick DohertyNational Clinical Lead, NHS Improvement - Heart

• Understanding the cardiac rehabilitation tariffhas been difficult and remains a focus at thesub-group meetings.

• Nurses reported that although the networkhas funded staff ‘back fill’ for the project; thenurses did not have the extra staff to fill whilstattending the national peer support meetingand local meetings. The nurses also foundallocating time for project work difficult attimes, specifically whilst undertaking theaudits.

• The nurses reported that the BACR and uptakeaudit was very time consuming and collectingthe data was not easy as the informationneeded was not accessible from the NationalAudit of Cardiac Rehabilitation (NACR) database.

The impact to dateThe project is still at its early stage ofdevelopment and many of the recommendationsare at the planning stage or earlyimplementation stage.

• All patients discharged from a programme willreceive a management plan and this will becopied to the GP.

• Patient referral and pre-assessment letters havebeen improved in response to patientinformation from patient discovery interviews

• A pilot using the Heart Manual as a basis forphase three rehabilitation has been funded byDorset Cardiac and Stroke Network and is dueto start in November 2009.

• All three programmes are inputting data to theNational Audit of Cardiac Rehabilitation andcommunication between the three sites hasimproved.

• A resource folder for services that patients canaccess has been updated at each site andinformation of patient services across Dorsetare shared.

• Psychological services have been mappedacross Dorset and referral pathways to theseservices have been identified.

Next steps

• Complete uptake and access audit and shareresults with the NHS Heart ImprovementTeam. Key findings from the audit will formrecommendations that will aid serviceimprovement and increase uptake and accessto cardiac rehabilitation.

• Undertake Geo mapping exercise to identifyif any locations across Dorset show variationin uptake.

• Introduce the Heart Manual as an additionalmethod of delivery to support those patientswho could not attend a traditionalrehabilitation programme. It was agreed thatthis would be a pilot in the rural parts ofDorset. The patient experience and viewswill be recorded using discovery interviews.

• Invite Leisure Services to join sub-group andbe involved in the project to forgepartnership working to expand the provisionof phase four in the community.

• Invite primary care colleagues to be involvedin the project to improve seamless dischargefrom cardiac rehabilitation to the community.

• Provide training to primary care colleagues oncoronary heart disease lifestyle managementto increase knowledge and awareness inorder to empower patients to self manage.

Contact details

Tracy Stoodley,Project Lead, Service Improvement Manager,Dorset Cardiac and Stroke Network.Email: [email protected]






Synopsis

What was the problem, challenge or issueyou were trying to resolve?The North of Tyne area is geographically diverse,with densely populated inner city and remoterural communities, and includes spearhead areasof deprivation. The project aims to inform NHSNorth of Tyne, to assist commissioning of apatient centred, cost effective, equitable CRservice for patients having PCI, CABG and MI,acknowledging there are other groups whowould benefit from rehab (HF, angina etc.). Theobjective is to resolve the differences in thecardiac rehabilitation services already establishedin the three PCO areas and to move towardsmore individualised and accessible services.

What were you trying to achieve in thetime available?The current cardiac rehabilitation service was tobe reviewed with a view to informingcommissioning decisions and addressing anygaps and inequities in services, whilst activelyengaging with stakeholders and patients in theprocess. Alongside staff and patient involvement,the project had to correspond and adhere tonational policy drivers for the core standards of acardiac rehabilitation service. The next stage ofthe project involves benchmarking providersagainst the new service specification. Goodpractice would be highlighted and shared andany duplication in the patient pathways betweenthe different stages of care were to beaddressed.

What was your solution(s) or approachto this?Both patients and professional stakeholdersrepresenting community and acute settings wereconsulted with on a regular basis. Severalstakeholder events were held to discuss theproposed service specification and also tocomment on the ongoing project report.Patient focus groups within cardiac rehabilitationservices were also held along with GP interviews.

What worked/ didn’t work to date?Communication with service providers in theinitial stages of the review could have beenimproved as it was felt that commissioners didnot keep professional stakeholders fullyinformed of the scope and proposed outcomes

of the project. However, as the projectprogressed, it was recognised that sustained andfrequent meaningful engagement with bothpatients and professionals led to the projectreport being fully representative from a widerange of stakeholders.

What would you do differently?As previously mentioned, communication wouldbe more explicit at the outset as there was anelement of uncertainty and concern about whatthe review would entail – fears about tenderingfor total service change and potential job losseswere real issues for provider staff. It should havebeen clearer at the start of the project that itwas a scoping exercise to produce a report toinform commissioning decisions rather than anend in itself.

Background

The project was a joint collaboration betweenthe North of England Cardiovascular Networkand NHS North of Tyne. NHS North of Tyne is ajoint management structure encompassingthree PCOs – North Tyneside, Newcastle andNorthumberland Care Trust. It also covers twoacute trusts – Northumbria Healthcare NHSFoundation Trust and Newcastle upon TyneHospitals NHS Foundation Trust. NHS North ofTyne commissions cardiac rehabilitation servicesfor a large and diverse population of around775,000 people and covers a geographicallydiverse area including inner city and remote ruralareas. NHS North of Tyne as a commissioningorganisation has experienced the commissioner-provider split at an early stage and as such thecommissioning functions of the PCOs are wellestablished.

The scope of the project was to map currentcardiac rehabilitation services and to includepatients who had MI, CABG and PCI ensuringthey had timely and equitable access torehabilitation services in line with nationalpolicies and guidelines. This service was to betailored to the individual and also needed torespond to the requirements of a very diversepopulation. The project spanned the entirepatient pathway and focussed on thecommunity element of this, i.e. discharge fromhospital. Each cardiac rehabilitation team wasstructured differently with some elements of the

Modernising a cardiac rehabilitation serviceNorth of Tyne, North of England Cardiovascular Network

service duplicated at different stages of thepatient pathway and as such, a revised andoverarching service specification was writtenalongside a project report, with both documentsgoing out to consultation with stakeholders andwhich would inform commissioning decisions for2009/10.

What we did

In spring 2008, a scoping workshop wasundertaken with the three cardiac rehabilitationteams from across the North of Tyne PCO areas.

The workshop identified that:• The models of service vary across the

three areas• The team that provide the service are

structured and resourced differently• There is duplication of service provision within

existing programmes.

These outcomes led to the conclusion that itwould be beneficial to explore the options formodernising the service from a one-size fits allprogramme to a menu-based rehabilitationprogramme tailored to individuals needs.

The project team consisted of:• Commissioning representation from NHS

North of Tyne (project manager).• North of England Cardiovascular Network• Clinical champion - consultant cardiologist.

The aims of this project are:• To ensure all that patients after MI, PCI and

CABG across the North of Tyne area haveequitable access to high quality and timelycardiac rehabilitation that identifies and meetsthe needs of the individual, encouragesengagement with patients and also ensuresthat the needs of a widely diverse populationare met

• To explore the potential of extending routinecardiac rehabilitation to other groups such asheart failure, angina and implantablecardioverter defibrillators

• To secure an agreed model of service forcardiac rehabilitation that can becommissioned across North of Tyne.

The intended outcomes of this project are togenerate recommendations that informcommissioning decisions for the forthcomingfinancial year.

These recommendations will ensure that:• The current pathway for cardiac rehabilitation

will be enhanced and changed where appropriate• Cardiac rehabilitation is tailored to the needs

of the individual patient and encouragespatients to identify their own goals

• Access to the service is equitable for thediverse population across North of Tyne

• The needs of patients with co-morbidities areaddressed in the best possible way

• Existing local training and education provisionis built upon with competency basedassessment, ensuring a skilled, knowledgeableand sustainable workforce throughout thecardiac rehabilitation pathway

• Robust systems are in place to measuresustainability and evaluate the service provision.

To achieve this we:• Held interviews with staff from within the cardiac

rehabilitation pathway across secondary care andcommunity services (NECVN)

• Interviewed a sample of GPs from across Northof Tyne (NECVN)

• Held patient and carer group discussionswithin Phase three cardiac rehabilitation groups,using a sample of groups that represented thediversity of the three PCO localities within Northof Tyne (NHS North of Tyne)

• Held patient and carer focus groups thatparticularly centred on the patient experienceafter Primary PCI (NECVN)

• Received professional stakeholder feedback oncurrent service provision which was comparedagainst patient and carer views and alsoreferenced against National Policies andStandards (NHS North of Tyne)

• Using all of the information and feedbackgathered, a service specification was drafted.We engaged with professional stakeholders toprogress the specification into an agreeddocument that was both realistic and met therequired national standards. The agreed servicespecification will ensure that cardiacrehabilitation will be provided in a high quality,consistent and equitable manner to accomplishthe ultimate intention of ensuring patientsachieve better outcomes after participating inthe cardiac rehabilitation programme (NHSNorth of Tyne and clinical champion).





All of the information is currently beingcompiled into a draft report to be submitted tothe NHS North of Tyne Executive CommissioningTeam as recommendations for commissioningdecisions for 2010/11.


The biggest issue that the project team hassought to address is inequity of service acrossthe three localities and identifying the barriers toproviding a menu-based, personalised service.There is currently a wide variation in howservices are provided such as waiting lists, inputfrom acute and community staff and the use ofthe home based programme to name a few.Having engaged with service providers todevelop a standard service specification for allthree PCO localities across North of Tyne to workwithin, we have been able to identify thesevariances and address them locally. Oneidentified barrier to ensuring that all cardiacrehabilitation patients receive the same quality,personalised service is the inconsistency ofexpertise in staff. It is acknowledged that allstaff provide a high quality service. However, it isalso recognised that without establishedprotocols, the needs of patients who haveadditional needs over and above the cardiacrehabilitation programme would more likely beidentified by staff with specialist skills. Forexample, if a member of staff has additionaltraining in psychological interventions, they aremore likely to recognise the need for a referralto a clinical psychologist.

The impact to date

The objective of this project is to makerecommendations to inform commissioningdecisions. Therefore, none of these changeshave been implemented at present so there areno outcomes to be identified as a result.Arrangements for collecting information,performance monitoring and evaluating thechanges to the service are currently beingidentified through the benchmarking processand will be established within the final servicespecification. One current benefit from thisproject has been the development of therelationship between the commissioners andproviders of the service. Although this is anoutcome from the project itself rather than anoutcome of the development of the service, wefelt that this was significant to mention.

Barriers, challenges and lessons

What worked and what didn’t work; whatyou would do differently or the same• Set clearer tasks within the project group and

ensure that mechanisms for reporting backinto the project team are more robust

• By engaging with both professionalstakeholders and service users to understandthe requirements of the service, we have beenable to develop a realistic yet high qualityservice specification with buy-in from serviceproviders

• Clearer definition of organisational roles andtheir input into the project.

North of Tyne total episodes 2007/08MI, PCI, CABG

1400

1200

1000

800

600

400

200

0PCI CABG MI only

Attendance at Phase 3 versus numberof episodes 2008/08

3000

2500

2000

1500

1000

500

0Episodes Attendance at Phase 3

Key challenges/ barriers to implementation/risks to delivery and how you overcamethem• A recognised challenge in implementing the

service specification is the requirement forrobust staff training to ensure consistent, highquality service delivery

• The potential bid for additional funding maynot be supported, however we envisage thatthe work undertaken in the project willstrongly underpin the business case andreduce this risk.

Key learning and sharing points

Leadership and planningCommissioners leading the project have ensuredthat the project feeds directly into thecommissioning cycle.

Clinical engagementA consultant cardiologist who is well respectedby service providers in community and secondarycare settings across all PCO boundarieschampioned the project. This has providedsignificant benefit when engaging withprofessional stakeholders, particularly whennegotiating the service specification.

Information transferThe outcomes of the project are yet to beimplemented and information transfer is beingaddressed through the service specification.

Provision in community settingsThe localities within NHS North of Tyne provide agood range of cardiac rehabilitation services inthe community however any identifieddeficiencies will addressed through thecommissioning process.

Work to address health inequalitiesThe service specification and pathway approachwill ensure equity in service provision andeliminate organisational barriers.

Next steps

• A bench marking tool has been developed andwe are currently benchmarking servicesagainst the proposed service specificationstandards

• All areas in North of Tyne (Newcastle,Northumberland and North Tyneside) are toagree a service specification and protocols inorder to provide a service that is equitable andaccessible to all members of the population

• There is a need to identify workforce trainingrequirements

• Cardiac rehabilitation is provided by differentstaff groups in different areas e.g. cardiacrehabilitation nurses or district nurses. Animportant aspect of future work will beensuring that individuals have access to thesame high quality training

• Outcomes of the project will informcommissioning decisions for the coming year.The bench-marking exercise is to be completedand the gaps and areas identified fordevelopment will provide the basis for a bidfor the Annual Operating Plan 2009/10

• Commissioners will continue with this workwith a view to implementing changes in2010/11.

Contact details

Tara TwiggService Improvement OfficerNHS North of TyneEmail: [email protected]: 0191 2172773

Carole DoddCHD Service Improvement ManagerNorth of England Cardiovascular NetworkEmail: [email protected]: 07876508194





Synopsis

The network formed a cardiac rehabilitationgroup in February 2008.

At the first meeting it was agreed that abaseline audit would be undertaken to highlightgood practice and identify gaps in service.

The main project identified from the baselinework was the redesign of cardiac rehabilitationservice in North Staffordshire. Increased capacitywas required in order to offer all cardiac patientsrehabilitation.

Background

The Shropshire and Staffordshire Networkconsists of four acute trusts (one tertiary centreand three district general hospitals), five primarycare trusts (PCTs) and one ambulance trust.

Two of the acute trusts work with the model ofa combined cardiac rehabilitation and heartfailure teams and the remaining trusts haveseparate teams.

When the baseline was completed a detaileddocument was drawn up of the services withinthe Network and all the documents can befound in the document store.

The network had completed a project initiationdocument detailing the aims and objectives for acardiac rehabilitation project and was keen tojoin the national priority project initiative.Having worked with the national team onprevious priority projects, the network knew thatthis would provide rehabilitation colleagues witha chance to exchange ideas and discuss

initiatives from other areas and to ensure thatthey received timely updates regarding nationalinitiatives within the field of cardiacrehabilitation.

What we did

When we joined the national priority project thenetwork had already started a baseline audit ofcardiac rehabilitation services available acrossShropshire and Staffordshire.

From the audit, gaps were identified and thefollowing aims and objectives agreed with therehabilitation project group.

• Improve the cardiac rehabilitation pathwayacross services within Shropshire andStaffordshire

• Share information and skills• Increase equity of access to rehabilitation.• Work with commissioners and trusts to

provide plans to reform rehabilitation serviceswhere required

• Assist organisations in the implementation ofelectronic submission to NACR

• Support organisations in the implementationof the myocardial infarction guideline

• Provide an overview of models currently beingfollowed across the network.

The outcomes of the project will be:• A redesigned service at North Staffordshire

which provides a patient menu drivenapproach to cardiac rehabilitation ensuringthat rehabilitation is also provided in thecommunity

• Improved uptake of cardiac rehabilitation inNorth Staffordshire

• Regular opportunities to share information andskills across the cardiac rehabilitationcommunity

• All trusts submitting electronic data to NACR• Equity in provision and access to cardiac

rehabilitation across the network.

A redesigned service for North StaffordshireShropshire and Staffordshire Heart and Stroke Network

The main project identified from the baselinedata was the redesign of services at NorthStaffordshire. This has now started and the newcardiac rehabilitation lead manager has beenappointed and commenced in post from July2009. The service improvement manager hashad initial discussions with the commissionersregarding their involvement in the rehabilitationproject and the cardiac rehabilitation lead issetting up meetings with the commissioners totake this work forward. Cardiac rehabilitation atStoke will be part of the fit for the futureprogramme which will see both PCTs workingtogether with the acute trust and the Networkto deliver a reformed service over the next fewmonths.

Paula Wells, the public and patient partnershiplead for the network, has been in contact withlocal groups to provide links to cardiacrehabilitation. A DVD is currently being trialledfor asian women and will be rolled out acrossthe country if successful.

There are two sites within the network whocurrently submit data to NACR manually andwork is in progress to ensure that both sites cansubmit information electronically by April 2010.A module has been purchased for one hospitalthat is being installed on their computer systemwhich will allow data to be input and sent toNACR. At the other hospital trust the networkinformation manager is working with staff toensure that their existing database can uploaddata to NACR.


The main priority is the redesign of services atNorth Staffordshire.

From the baseline audit it was noted that aredesign of service and an increase in workforcewas required to ensure that the team providedequity of access into cardiac rehabilitation for allappropriate cardiac patients to meet nationalguidelines of best practice. This will require theteam to increase capacity by redesigning theservice and reviewing the workforce skill mix andnumbers. This notion was also eluded to in theanalysis of the patient satisfaction surveyscompleted from 2006 to 2009.

The need to create capacity is demonstrated inthe graphs below:

The number of patients who have receivedphase one rehabilitation is falling whilst theamount of work at the trust is growing. Thishighlighted the need for training to be providedto the nurses on the cardiac ward so that theycan provide phase one rehabilitation to patientswho are discharged out of the teams normalworking hours:



Received Phase 1 Rehabilitation

Number of patients who attended Phase 3 Rehabilitation Services

Similarly this graph demonstrates that with thenumber of procedures being undertaken at thetrust, cardiac rehabilitation should be offered toa larger number of patients.

The service redesign will include:

• Review of current practice relating tophase three care

• Rapid access into phase three rehabilitation• Risk stratification for patients to identify

location of phase three care• Ensure additional capacity in the community

for phase four cardiac rehabilitation



• Increase in workforce and review of skill mix• Access into cardiac rehabilitation for heart

failure and patients post elective coronaryrevascularisation.

Dr R Butler, consultant cardiologist and JamesRushton, the cardiac rehabilitation lead managerwill be leading the work and a paper has beenproduced detailing the additional resourcesrequired to ensure that the rehabilitation servicemeets the needs of its patients.

Within Northern Staffordshire the two PCTs arecommitted to a programme of developingservices through the initial work and liaise withthe commissioning leads. The next round ofinvestment will include cardiac rehabilitation.This work will commence in September and dueto the background work already completedshould move fairly rapidly.

The Impact to date

The main project is still in its infancy and data isbeing collected on a monthly basis to monitorthe take up of cardiac rehabilitation so that asthe service and additional capacity is availablethis can be recorded as a measure of success ofthe project.

The analysis of the patient satisfactionquestionnaires has been a very powerful tooland will be used to inform the project of areasthat need to be improved. The questionnaire issent to all patients and will be used as anongoing measure (see appendix 9).

The project will also monitor the uptake ofrehabilitation within the community once thisfacility is available to patients.

Feedback from patients who attended theStafford Saturday education group has beenobtained. The group is run for patients bypatients and provides an informal atmospherewhere patients can chat and provide support toeach other. Members of the cardiacrehabilitation team are also in attendance toprovide support and advice and education isprovided by a dietician, consultant cardiologist,etc. There are four programmes per year thatlast for four weeks. This is an excellent exampleof good practice and has been fed back to thenational priority project lead.


One of the biggest barriers for the main projectwas not having the lead rehab manager in postuntil July 2009. However, the project is nowgathering pace in terms of proposed new servicemodels. Yet for these to be successfullyimplemented the support and vision of thecommissioners is vital to provide synchrony ofservices across North Staffordshire.

The provision of cardiac rehabilitation within thecommunity is key to the plans for the future ofthe service. This will bring rehabilitation closerto the patient and free up additional spacewithin the cardiac gym to accommodate allpatients who require rehabilitation.

Next steps

The project is fully integrated into the workinglife of the staff at University Hospital of NorthStaffordshire and will be sustained oncecompleted as it will be a totally new way ofworking for the team. Once the new pathwayhas been agreed, protocols and reviseddocumentation will be produced in line with thenew ways of working. The network informationmanager is working with the lead forrehabilitation to look at introducing documentsthat can be scanned both for providinginformation to NACR and the departmentdatabase and also for the patient satisfactionsurveys. This will free up clinician time fromadministrative chores.

Contact details

James Rushton,Cardiac Rehabilitation LeadTel: 01782 553361

Jane Barnes,Service Improvement ManagerTel: 07768 710697

NB: Appendix 9 is available fromthe NHS Improvement website at:www.improvement.nhs.uk/heart/rehabprojectsummaries

Synopsis

This project reviewed current cardiacrehabilitation services offered to the Surreypopulation, to enable the delivery of equitableservices, in preparation for the commissioningintentions of Surrey PCT and development of alocal tariff.

To address the inequities in service provision forSurrey patients a project group, involving keystakeholders, was formed by Surrey Heart andStroke Network. Services were mapped againstan agreed ‘ideal cardiac rehabilitation pathway’,following review of national guidelines byproject group. Gaps in service provision wereidentified and service specification and businesscase agreed to enable the development of amore patient centred comprehensiverehabilitation service, in particular to enablerehabilitation closer to home.

Key challenges included development of robustmethods of data collection to assess uptake ofpatients to phases, gaining consensus ondefining rehabilitation phases and overcomingpublic and professional perceptions regardingsafety of patients receiving phase threeprogrammes in community and leisure centrevenues.

Background

Surrey has five acute hospital providers whooffer cardiac rehabilitation phase one, two andthree. Two of the acute hospital providers servetwo neighbouring PCTs. Patients followingcardiac surgery or cardiac events in Tertiarycentres are referred back to acute hospitalproviders for rehabilitation.

All providers had limited experience ofnetworking across Surrey and sharing practices.A significant difference in cardiac serviceprovision has led to known inequalities in serviceprovision for Surrey patients. However, therewas no previous evidence of base lining of allservices in one report. Two out of the fivehospital localities provide community basedphase three services. One out of the fivelocalities provides a comprehensive cardiacrehabilitation programme, including a choice ofhospital, community or home programmes using

facilitated manual based programmes.In addition service varied in access to patientsgroups, nature, and duration and informationmanagement.

In addition, there was no network wideagreement on a minimum standard for operationof cardiac rehabilitation. Consequently, it was feltimportant that in preparation for the developmentof an agreed service model and specification andbase lining of services against this standard toidentify gaps in service provision and agreedevelopment plans.

Funds had been identified for cardiacrehabilitation across Surrey, however during thelife of project it had become increasingly apparentthat such funds were now limited. As a result theminimum output for the project was an agreedstandard for cardiac rehabilitation services andidentification of gaps in service provision and adevelopment plan for each provider.

What we did

• A project group was formed and chaired by aconsultant cardiologist who also attendsSurrey Cardiac Clinical Reference Group. Keystakeholders from all providers and disciplineswere invited. Four meetings were heldbetween June and September 2009



Improving access for Surrey patientsSurrey Heart and Stroke Network



• An ideal cardiac rehabilitation pathway wasdeveloped and agreed, in collaboration withkey stakeholders from current providers inSurrey. Pathway was developed followingreview of current literature and guidelines oncardiac rehabilitation

• Services were benchmarked against keyelements of the ideal cardiac rehabilitationpathway. Mappings were carried out byvisiting each provider and by presentations ofproviders at each meeting. Patient pathwaysfor all phases were mapped

• Each provider was requested to providereferral, activity data and coded data perprimary diagnosis and PCT e.g. patients withangina, MI, PCI, heart failure, cardiac surgery,and with implantable cardiac devices

• Patients views are being gained by commentcards of patients who have attended servicesto determine comments regarding preferredchoice of venue for phase three rehabilitation

• Patients who did not attend for phase threewere sent ‘reasons why’ letter

• Cardiac rehabilitation specification currentlybeing consulted with Surrey Cardiac ClinicalReference Group and via patient groups.


• Development of services with no investment• Development of a local tariff – as services

involve professionals from a variety oforganisations and because all services areincluded in block contracts the developmentof a local tariff will mean monies will be takenout of acute trust contracts, this maydestabilise existing services as workforceusually undertake other cardiology servicessuch as Rapid Access Chest Pain Clinics orsupport other rehabilitation services

• Development of robust methods of datacollection – concerns were raised at an earlystage that many providers were unable topresent activity for all phases per diagnosticgroup and PCT. Data was also collecteddifferently by providers. Many providers alsohad different interpretation for input of datato NACR.

Impact to date

Key outcomes of the project included:1. The cardiac rehabilitation base lining

document was presented to Surrey PCTwhich identified the gaps and gaverecommendations.

Key findings included:• Gaps in current service provision across all

providers, in particular community basedrehabilitation programmes (see appendix 10,tables 1 and 2)

• Variation in robust methods for data collection– not all providers’ sign up to one year followup questionnaire. Not all providers can reportactivity per diagnostic group therefore havedifficulty in reporting % uptake of patients toeach phase (see appendix 10, tables 3 and 4).

• Variation in governance arrangements – notall providers have operational proceduresdocumented with lines of responsibility toconsultant cardiologists. Those services thatwere able to provide guidelines were notoutlined as an integrated service to all phases(see appendix 10, table 5).

2. Network wide minimum standard for cardiacrehabilitation services phase one, two andthree, agreed by project group (can beviewed on NHS Improvement website at:www.improvement.nhs.uk/heart).

3. Network wide model for cardiacrehabilitation agreed by project group.

4. Network wide monitoring and evaluationcriteria agreed.

5. Robust methods for data collectionimplemented across all providers

6. Networking of all cardiac rehabilitationservices across Surrey and willingness toshare and develop practice.

7. All providers agreed to undertake one yearNACR follow up.

8. All providers agreed to use DNA evaluationform for those patients who do not attend.

9. Methods for consulting with user’s agreed,comment cards, support groups, organisationof cardiac rehabilitation public awarenessevent November 2009.

Barriers, challenges and lessons learnt

• Changing perceptions of clinicians regardingtraditional versus new ways of working whennew service model could threaten role/ job.This was overcome by always trying to getclinicians to ’think outside of the box’ andwearing the ‘hat of the patient’

• Changing perceptions of patients – manypatients did not understand that they are notat risk by undertaking phase threeprogrammes at other centres outside ofhospital. This could bias obtaining user views.Hence, we have planned public awarenesssessions on cardiac rehabilitation

• Managing clinician expectation of the projectgroup in a climate of PCT financial constraint.Needed to demonstrate some quick wins,frequent monthly meetings enablednetworking and sharing of work. Everymeeting had a product and tangiblemilestone outcome. The group did not fullyunderstand commissioning processes andchallenges. Therefore were initially defensiveand reactive to any base lining work anddefining model of rehabilitation. In hindsight,it would have helped if clinicians could haveattended more NHS Improvement supportdays but it was difficult to gain commitmentfrom organisations but we did manage tonetwork with neighbouring PCTs to obtaininformation and support.

Next steps

• The group is to continue to meet to developa plan of how individual providers will meetminimal standard of specification

• Surrey Heart and Stroke Network to facilitateall providers to develop plans to streamlineservices to meet standard and to monitorachievements of plans

• Cardiac rehabilitation data to be reportedquarterly and Surrey Cardiac Clinical ReferenceGroup

• Public awareness day to celebrateachievements and consult on model of cardiacrehabilitation

• Specification/ business case to be supported byPEC within Surrey PCT and to be progressed toobtain increased community basedrehabilitation services.

Contact details

Sue CottleService Improvement ManagerSurrey Heart and Stroke NetworkEmail: [email protected]

Felicity DennisNetwork ManagerSurrey Heart and Stroke NetworkTel: 07894599644Email: felicity.dennis.nhs.net






Synopsis

What was the problem, challenge or issueyou were trying to resolve?The challenge was to increase the uptake ofphase three cardiac rehabilitation across theBlack Country Cardiovascular Network (BCCN)and ensure that all eligible patients are beingoffered cardiac rehabilitation.

What were you trying to achieve in thetime available?We are hoping to identify reasons/barriers whypatients are declining cardiac rehabilitation anddetermining whether there is a significantdifference in the level of rehabilitation uptakebetween various demographics. If time permits,interventions to address any barriers identifiedwill be trialled.

What was your solution(s) or approachto this?A three month audit was undertaken of all postMI and revascularisation patients dischargedfrom hospital in the BCCN. This formed thebaseline data for:

• Current uptake• Reasons for decline• Possible inequalities likely to result in patients

not being referred or declining their invitation.

What worked/didn’t work to date?The three month baseline audit was a successand proved to be very thought provoking withrespect to the referral process, trends in uptakeand the quality of information collected. Inparticular, the baseline audit has helped to:

• Identify potential inequalities in the referralprocess

• Identify potential inequalities in uptake,particularly with respect to age and gender

• Identify that some of the data are ambiguous,with respect to both non-referral and non-uptake

• Improve our audit forms to enable us to collectbetter quality data

• Raise the profile of cardiac rehabilitationwithin the care pathway.

What would you do differently?• The audit numbers (555) allowed us to

interrogate the data on a network level butnot on a locality level. Accordingly, thebaseline audit was a successful ‘pilot’ but wewould ideally increase the audit sample size toallow us to look at the data on a locality level

• Ensure that staff collect more accurateinformation on non-referral and non-uptake.

• Ensure that staff complete all audit questions.

Background

The Black Country Cardiovascular Networkhas three mature and comprehensive CRprogrammes that are well respected by thenetwork and its component PCTs. The networkcovers Dudley, Walsall and Wolverhampton.The rehabilitation services are based at:

• Russells Hall Hospital, Dudley• Heart Care Walsall• New Cross Hospital, Wolverhampton.

Accordingly, the PCTs are keen to encourage allpatients to participate in the CR services.However, in line with national statistics, theprogrammes were aware that the generaluptake of CR services remains frustratingly stableand sub-optimal.

The network was already embarking on its auditproject at the time of the national priorityproject being announced. The network projectmet the criteria of the national project and itwas felt that signing up as part of the nationalproject would be more beneficial than carryingout the project solely within the network. Bysigning up nationally it would allow us to:

• Keep up to date with the national picture• Attend peer support meetings• Look at outcomes of project and address actions• Receive training on use of improvement

reporting system, demand and capacity etc• Share learning• Pick up ideas• Get national clinical director expertise• Showcase work in publications/conferences• Have improvements written up and published

nationally• Work directly with NACR• Influence commissioners.

Audit on the uptake of phasethree cardiac rehabilitationBlack Country Cardiovascular Network

What we did

The Network Standard Group for Rehabilitationembarked on a three month audit to obtainbaseline data for referral and uptake trends. Thiswould generate enough numbers to allowstatistical analysis and a short enough period oftime to detect any ‘flaws’ in the audit process.All three programmes fully complied with theaudit and referral/uptake information wascollected on 555 patients.

Wolverhampton City PCTs Public HealthDepartment kindly agreed to take responsibilityfor the statistical analysis of the data and thiswas duly undertaken.

The project team considered the results whichdid highlight potential issues with both referraland uptake to CR services. For example, theaudit demonstrated unequivocally that elderlyand female patients were less likely to accepttheir invitation to CR. However, it also becameevident from the audit that some of the datawere ‘ambiguous’ and thus potentiallymisleading.

The project team presented the results of theaudit widely amongst colleagues and patientrepresentatives within the network, gatheringfeedback at every opportunity. The project team,having had time to reflect, sought permissionfrom the network to prepare for a nine month



improved audit which will attempt to eliminatethe ambiguity of the data and provide thepower required to interrogate the results onboth a locality and network level.

Support of the network was duly confirmed forthe audit and preparations were put in place;the preparations included, the improvement ofthe referral form, education of the referral staffto ensure complete and accurate data collection,education of referral staff to ensure appropriatereferral/non-referral.

During this time it has also been decided tofocus on the female and elderly groups thatdeclined their invitation to CR, as these data arefairly unequivocal and are very much inline withnational trends. Accordingly, the reasons fordecline will be investigated further in case anycommon issues can already be identified.

A one month trial of the new audit form wassuccessfully completed in June 2009 and thestarting date for the nine month audit confirmedas 1 September 2009.

The project aim is to help identify barriers andinequalities that may exist within the BCCNs CRservices that result in lower than optimal uptakeof these services. In the first instance, the projectwill focus on post MI patients and patientshaving undergone revascularisation. The projectwill then attempt to address any barriers/inequalities identified in a bid to increaseuptake.

It is anticipated that the project will, as aminimum, inform commissioners whether alleligible patients with the above diagnoses withinthe BCCN are being offered CR services. Thiswill, in the process, reveal whether the referralprocess is responsible for introducing anyinequalities. The project will then investigatewhether the reasons given by patients decliningtheir invitation identify any commonbarriers/inequalities in the current CR services.On the assumption that certain barriers/inequalities are identified the project willattempt to address these with new initiatives.




The main issue that the project sought toaddress was to identify potential ‘groups’ ofpatients that were either not being referred orwere not accepting their invitation to CRservices. The ultimate challenge is to eliminatehealth inequalities within the referral system andto increase the percentage take up of CRservices in the BCCN.

The impact to date

Changing the audit form and having discussionswith the referring health professionals, hasalready resulted in fewer non-referrals and morepatients being offered home exerciseprogrammes. For further information and resultson the audit see appendix 11.


Leadership and planningThe project enjoyed effective leadership andplanning from the following, to start the projectand to sustain it:

• Rehabilitation leads• NCA for CR to NHS Improvement• Cardiac nehab network standard group• Audit project team• Network facilitator.

The involvement of the above has beenextremely useful in maintaining the high profileand commitment to the project.

Clinical engagementIt was essential to obtain clinical engagement; inthis project this was particularly the case for theproject team and for the clinicians that weremaking referral decisions and collecting data.The baseline audit has also confirmed this to bethe case, particularly as we are asking theclinicians to take on additional tasks during thelife of the project.

The inclusion of these clinicians in projectfeedback has been appreciated and will,hopefully, help to maintain their commitmentfor the duration of the project.

Information transferThe information obtained from the project hasbeen shared at network and locality meetings tohelp maintain the profile of the project. Thisappears to have worked well and also with theclinicians directly involved in the project. Theinformation has also been presented more widelyat ‘opportunistic’ events that were interested inour results.

It has been very beneficial to have an identifiedperson in charge of data/information collection toensure appropriate safekeeping/analysis and spread.

Work to address health inequalitiesThe project has already clarified that there isnothing that beats having a look at your owndata! The data collected to date, and theirsubsequent analysis, has already proved to bethought provoking, highlighting a number ofpotential issues with respect to health inequalities.

It has been useful to include the MOSAICsoftware in our data collection as this enables aninsight to potential correlations between levels ofdeprivation and referral/uptake patterns.

The project has already confirmed the nationaltrend that elderly and female patients are lesslikely to accept their invitation to rehabilitation.

Next steps

We have agreed to undertake a nine monthaudit, using the new and improved audit form,from September 2009. This audit will give us thenumbers required to interrogate the data on alocality level as well as on a Network level andallow us to identify service improvements so thatwe can introduce any new initiatives to improvethe uptake to cardiac rehabilitation.

Contact details

Ruba MiahNetwork FacilitatorE-mail: [email protected]: 01902 694410


Synopsis

This project was collaboration between theNorth West London Cardiac and StrokeNetwork and Imperial College Healthcare NHSTrust. It involved the cardiac prevention andrehabilitation team for Charring Cross andHammersmith Hospitals. There had been a gapidentified in the cardiac rehabilitation servicesoffered to PPCI patients that came intoHammersmith Hospital. These patients werefrom a wide geographic area covering NorthWest London and beyond. It was felt that thosePPCI patients from outside the hospital’s localpopulation were not being picked up andreferred on for cardiac rehabilitation. The projectaimed to ascertain whether these cohorts ofPPCI patients were receiving cardiacrehabilitation. It also aimed to make changes toimprove the service, through increasing staffingto ensure that these patients were picked upand setting up a system to audit and monitortheir onward referral.

Background

There had been a successful primary angioplastyservice running at Hammersmith Hospital since2003. However, there had been an issue withthe cardiac rehabilitation team (based atCharring Cross Hospital) not always picking upthese patients and referring them on forrehabilitation. The cardiac rehabilitation team atCharring Cross decided to set up a new systemfor identifying these patients and ensuring thatthey were appropriately referred for cardiacrehabilitation.

The project aims were as follows:• To look at ways of identifying all patients

admitted to the primary angioplasty service• To ensure that they receive Phase one cardiac

rehabilitation and onward referral to theirchosen cardiac rehabilitation centre

• To follow up referred patients to establishwhether they were offered cardiacrehabilitation, if they took up the offer, and ifthey completed their programme

• To map the type of CR programme the patientwas offered and to provide a clear picture ofCR provision across the sector

• To develop close working with the referringcentre’s and having up-to-date information onservice availability and type so that patientscan be fully informed of what is available tothem.

What we did

A new nursing post was appointed to thecardiac rehab team, whose remit was to pick upall of the patients that required cardiacrehabilitation and yet who lived beyond theboundaries of the local primary care trust.A new database was set up to record thepatient’s details and where they should bereferred to for their cardiac rehabilitation.A detailed patient information leaflet wascreated to give all patients information aboutrehabilitation as well as contact details for all ofthe fourteen different rehab centres in NorthWest London (see appendix 12). This wouldenable these patients to be able to choosewhich centre they could be referred onto.



Referral to cardiac rehabilitation for PPCI patientsNorth West London Cardiac and Stroke Network



There is therefore now a clear system foridentifying out-of-area patients, offering them achoice of CR provider and tracking their referralto the provider to ensure they are followed up.There was also a telephone audit undertaken inorder to ascertain how many patients werereceiving rehab prior to this system wasintroduced. This audit showed that as few as20% of patients were receiving rehab prior tothis system being introduced – although theresponse rate to this audit was lower thanexpected due to difficulties in getting through tomany patients.


Cardiac rehabilitation departments use differentdata systems for collecting patient data andmaking referrals. It was therefore difficult toreceive up-to-date data on whether this cohortof patients had received rehab at the differentcentres of North West London. To be sure ofmonitoring what happened with these PPCIpatients, it was therefore necessary to set up aseparate excel database for tracking this cohortof patients.

The impact to date

During a six month period from January to June2009, 150 PPCI patients have been picked upand either offered rehab at the department atCharring Cross Hospital or referred onto anothercentre where appropriate.

Next steps

The cardiac rehabilitation department atCharring Cross Hospital will continue to use thissystem for monitoring cardiac rehabilitationreferrals for PPCI patients across the sector.North West London Cardiac and Stroke Networkwill ensure that the other centres offering PPCIin North West London also have systems in placefor this cohort of patients. In addition, theinformation leaflet used for this project willcontinue to be used and may well be rolled outacross the sector.

Contact details

Antoinette ScottAssistant Director, Cardiac ServicesNorth West London Cardiac and Stroke NetworkEmail: [email protected]


Synopsis

• A cardiac rehabilitation service baselineassessment completed in December 2007 anda stroke service baseline assessmentcompleted in July 2008 within North WestLondon highlighted that vocationalrehabilitation was a missing factor within thepackage of care across the majority of theserviced PCTs by the North West LondonCardiac and Stroke Network (NWLCSN)

• This project aimed to design a pathway forvocational rehabilitation that is cost neutral forproviders to pilot

• In the time available a pathway was designedwith referral templates and criteria andestablished referral links between NHSproviders and specialist department of workand pensions funded vocational rehabproviders

• The NHS organisations involved were• Imperial College Healthcare NHS Trust:

Charing Cross and Hammersmith Hospitals,Cardiac Prevention and Rehabilitation Team

• Ealing Hospital NHS Trust: Cardiac Preventionand Rehabilitation Team

• Shaw Trust• NHS Improvement Heart Team

• The main outcome of the project was that acost neutral pathway was designed which canbe shared to organisations to pilot within anyremit of healthcare. The limitation to thisproject is that NHS providers learnt keyinformation from the project set up stagewhich was passed onto the patient, resultingin fewer referrals and therefore datacollection. The uncontrollable factor was thatthe type of patients accessing rehab servicesoften did not require vocational rehab supportfor various reasons.

BackgroundThe project comprised a simple referral pathwaybetween cardiac rehabilitation and an externalvocational rehabilitation provider. This providerwas Shaw Trust, a national charity organisationwhich has supported disadvantaged individualsin the labour market due to disability, ill healthor other social circumstances over the last 25years. In the last year alone 60,055 individualswere supported nationwide (Shaw Trust, YearEnd Report 2006-07).

The project aims were:

• To provide a vocational rehabilitation pathwayas an additional resource within a cardiacrehabilitation menu

• To allow patients to receive specialistinformation and guidance on vocationalrehabilitation

• To increase the number of patients (if eligiblefor the service) within a working age returningto employment having received specialistsupport based on their post cardiac eventneeds

• To support those patients who were previouslynot employed (if eligible for the service) toseek methods for coming off state benefitsand attaining full time employment based ontheir post cardiac event needs

• To increase the vocational rehabilitationknowledge of the healthcare professionalsinvolved in the pilot

• To increase the number of resources availablewithin the remit of cardiac rehabilitation

• To allow patients to receive more continuityof care.

What we didA detailed pathway document was designed toallow patients with vocational need to bereferred onto independent sector supportorganisations (see appendix 13).

Pathways were designed to allow the patient toaccess one of three services: a job retentionprogramme for those at risk of loosing their jobdue to their medical event, a job startprogramme for those who wish to engage inemployment and a group education programmefor those patients who may not want to engagewith support agencies, preferring to attendgroup education settings within the outpatientsetting.

The project aims were:

• To provide a vocational rehabilitation pathwayas an additional resource within a cardiacrehabilitation menu

• To allow patients to receive specialistinformation and guidance on vocationalrehabilitation



Vocational rehabilitation projectNorth West London Cardiac and Stroke Network

• To increase the number of patients (if eligiblefor the service) within a working age returningto employment having received specialistsupport based on their post cardiac eventneeds

• To support those patients who were previouslynot employed (if eligible for the service) toseek methods for coming off state benefitsand attaining full time employment based ontheir post cardiac event needs

• To increase the vocational rehabilitationknowledge of the healthcare professionalsinvolved in the pilot

• To increase the number of resources availablewithin the remit of cardiac rehabilitation

• To allow patients to receive more continuityof care.

Expected outcomes

• A greater synergy between vocational servicesand the cardiac rehabilitation teams will existso that patients are better prepared and havea continual reinforcement when returning toemployment

• Involved organisations will acquire up to dateinformation from service collaboration

• Coping strategies will be established amongstidentified patients to aid their return toemployment process and to reduce thenumber of stressful episodes

• A reduction in inequalities of service related tovocational rehabilitation within cardiacrehabilitation programmes

• Existing time recourses for cardiacrehabilitation services can focus on enhancingother aspects of their service

• Improved quality of life for those receivingthis service

• Referred patients receive specialist vocationaladvice and support.

Several meetings were set up between providersand Shaw Trust to develop the pathway readyfor a six month service evaluation period. Oncereferrals were live within this time frame,providers found it difficult to locate appropriatepatients suitable for the service, and oncelocated patients often did not require the serviceor did not fit the referral criteria. As aconsequence referral criteria and documentationwas simplified.


The biggest challenge was locating appropriatepatients to refer to this service. As it was fundedvia the Department of Work and Pensions(DWP), strict eligibility criteria was in place toallow government funding to follow eachpatient once accepted for vocationalrehabilitation. This resulted in no successfulreferral and episodes of vocational rehabilitationcompleted. Patients were referred, screened andfound to be either not suitable or gained theappropriate information to reduce theiremployment issues and that an episode ofvocational rehab was not required.





The impact to date

By establishing this pathway healthcareprofessionals at the pilot sites gained furtherknowledge of vocational advice and were ableto relay this information to their patientswithout the need for specialist support.This pathway would positively impact anorganisation as it does not require a set up cost- it is a simple referral process completed withinusual outpatients settings, and the eligiblepatients are funded via DWP revenue streams.


The main barriers initially were the requirementto increase the skills of healthcare providers inthe terminology associated with vocationalsupport.

Repeating this project, to ensure that referralswere adequate more pilot sites were recruited.This was not permitted within the pilot timeperiod as Shaw Trust could only designate oneemployee to accept referrals with limitedgeographical scope

Continuing the project, suggestions would be toswitch vocational rehab providers to ones withan increased capacity to service the sector,recruit more pilot sites and/or open the pathwayto other areas of healthcare rehabilitation.

Next stepsThe project requires a re-launch to gatherevaluation data or issue the pathway design toother networks to pilot.

Contact details

Jason AntrobusSenior Project ManagerNorth West London Cardiac and Stroke NetworkEmail: [email protected]


Synopsis

Cardiac rehabilitation is proven to be value formoney and is aligned with Chapter 7, CHD NSF.The Peninsula Heart and Stroke Network aims toprovide commissioners current, relevantinformation to inform local decision making onthe provision and delivery of high quality cardiacrehabilitation services across the Peninsula in linewith new national guidance, based on bestpractice and value for money, and to ultimatelybenefit people diagnosed with Coronary HeartDisease (CHD) and their carers.

Background

Despite the publication of the evidence therehas always been patchy development of cardiacrehabilitation services both nationally and acrossthe SW Peninsula. This is chiefly due to the factthat funds were subsumed by more pressingCHD priorities such as the achievement of hardtargets associated with revascularisation. At thistime there was no national tariff for cardiacrehabilitation making it difficult to understandthe costing implications. Few NHS organisationshave developed tight commissioningspecifications for cardiac rehabilitation or haveaudit data enabling them to understand theexact cost of cardiac rehabilitation and whatvalue is being delivered for their investment.Patients derive immense comfort and supportfrom cardiac rehabilitation and December 2007,thousands of heart patients around Englandcampaigned to local MPS and PCT ChiefExecutive Officers (CEOs), for the increase ofservice provision, to allow all heart patients whocan benefit to have access to high-qualitycardiac rehabilitation. A number of patientslobbied and campaigned for better cardiacrehabilitation services both nationally and locallywhich raised the profile of cardiac rehabilitationwith PCTs across the South West.

What we did

In 2008, the Peninsula Cardiac Network wascommissioned by the Peninsula CommissioningGroup to undertake a review of existing cardiacrehabilitation services within the peninsula andto draw up a new proposal which incorporates

PCI patients, and provide commissionerssufficient information and advice to enable themto address the inequity of cardiac rehabilitationservices across the peninsula.

A scoping exercise was undertaken to reviewcurrent service provision for Devon, Torbay,Plymouth and Cornwall PCTs. Compared withthe vast body of evidence being collatednationally, it was evident that cardiacrehabilitation was not only good for patients,but value for money. However, in scopingcurrent local services, it was clear that to meetthe full demand, new ways of working had tobe considered for the future.

As a network, cardiac rehabilitation has alwaysbeen one of our main priorities and this islargely due to our highly motivated Peninsulawide patient group ably led by Liz Clark. Thenetwork is often required to provide updates tothe PPISG regarding both national and localcardiac rehabilitation issues which include thetariff implications.

Throughout this work, the network hasconsidered the excellent work being provided byother cardiac rehabilitation services across thecountry and this has provided us valuable insightto better understand how cardiac rehabilitationservices can be developed in the future.

Proposal modelThe cardiac rehabilitation paper proposes a newmodel for delivering services offering all thatpeople admitted to hospital suffering fromcoronary heart disease (CHD) have been invited,prior to leaving hospital, to participate in amultidisciplinary programme of cardiacrehabilitation based on their individual level ofrisk and need, through a menu of servicesavailable locally.



Cardiac rehabilitation across the PeninsulaPeninsula Heart and Stroke Network



Menu-based approach (also knownas menu-driven model)This approach still comprises the corecomponents required of a comprehensivecardiac rehabilitation service:

• BACR Standards and Core Components 2007)taking into account patient individual needs(i.e. not every patient requires every elementof the programme) also disease complexity,therefore offering a more inclusive model ofcare, with greater patient choice and flexibility.Therefore, this model is based on an individualperson’s assessment of physical, psychologicaland social needs for cardiac rehabilitationusing a risk stratification and guidance.

Proposed recommendations• Cardiac rehabilitation should be provided as a

central service across both the acute andprimary care with a 'one point of contact' toaccept all referrals. It should be developed inaccordance with national standards andcompetencies, such as those set out by NICEand BACR including the implementation of theNACR database

• All patients should receive an individuallydesigned menu driven programme relevant fortheir needs

• PCTs should develop a commissioningspecification for cardiac rehabilitation serviceswith key performance indicators (KPIs) andquality markers that will need to be achieved

• Cardiac rehabilitation including secondaryprevention should overlap where appropriatewith the management of other diseases

• PCTs should develop a service directory, givinga clear description of all relevant programmesand services including content of the serviceand referral pathways

• The PCT should develop a provider lead suchas ‘life style’ service co-ordinator to workclosely with commissioners to ensure servicesare commissioned in a co-ordinated mannerand relevant schemes are integrated.

EndorsementThe cardiac rehabilitation paper was drafted andsubmitted to for the Peninsula CardiacCommissioning group where it received fullendorsement. The document was also submittedto the NHS Improvement Programme – fromwhich, Professor Patrick Doherty, NationalClinical Lead, NHS Improvement, expressed aninterest in the work and requested the networkto further consider writing a risk stratification tocombine with the model.

Risk Stratification Working GroupThe network implemented a small workinggroup from each sector of the peninsula toprovide a generic risk stratification documentthat would be used in conjunction with ageneric service specification.

This group consists of; cardiac rehabilitationnurses, cardiac rehabilitation physio, a manager,a service improvement manager and communityservice provider for phase four. The group hasaccess to both GPSI and cardiologist (networkclinical lead) and has met twice to agree anoutline of what the risk stratification shouldinclude.

This is in the process of nearing completionwhere is will be examined by the networkclinical lead cardiologist before submission to thecommissioning group. It will also be givenconsideration by the national team and PatrickDoherty.

Next stepsAs a result of this, commissioners requested ashell service specification be written to draw themodel together.

Shell Service Specification (SS)A ‘shell’ service specification to define minimumstandards, performance indicators andmonitoring/audit has been drafted and will bereviewed by a commissioner led sub group todiscuss all aspects of providing comprehensivecardiac rehabilitation services.

The biggest issue/ challenge

This model poses a challenge for existing phasedmodels but also offers great opportunities togive consideration to all cardio and vasculardisease prevention. It suggests the alignment ofboth secondary and primary prevention andsupports integration of existing services using alifestyle lead role to co-ordinate these services.


The concept of using an individual riskstratification method to provide and offerpatients a choice has brought many challengesfrom cardiac rehabilitation teams. Breakingdown barriers to change mindsets has takentime and quite often require reminding thatpatients should be provided appropriate servicesbased on their individual level of risk. Anexample would be that not all PCI patientsrequire a full programme of cardiacrehabilitation, however, they still requirelifestyle modification advice.

Next steps

The network is currently scoping and developinga skills competency framework based on thecompetencies Skills for Health. This is toenhance the proposed model and providecommissioners a full comprehensive option ofchoice for setting up cardiac rehabilitationservices which may provide further scope forfuture ‘prevention’ service developments.

Contact details

Chrissie BennettPeninsula Heart and Stroke Network,Email: [email protected]: 01752 434945



National Project Leads

Linda BinderNational Improvement LeadNHS ImprovementEmail: [email protected]

Professor Patrick DohertyNational Clinical Lead to NHS ImprovementEmail: [email protected]

Dr Jane FlintNational Clinical Advisor to NHS ImprovementEmail: [email protected]

Project Managers

Ciara ScarffLong Term Conditions Commissioning Manager,Derbyshire PCTEmail: [email protected]

Alice JennerProject Manager,South West London Cardiac and Stroke NetworkEmail: [email protected]

Michelle BullSenior Project Manager,South West London Cardiac and Stroke NetworkEmail: [email protected]

Louise BevingtonActing Lead Cardiac Specialist Nurse,Scunthorpe General HospitalEmail: [email protected]

Tracy Stoodley,Service Improvement Manager,Dorset Cardiac and Stroke NetworkEmail: [email protected]

Tara TwiggService Improvement Officer,NHS North of TyneEmail: [email protected]

Jane BarnesService Improvement Manager,Shropshire and Staffordshire Heartand Stroke NetworkEmail: [email protected]

Felicity DennisNetwork Manager,Surrey Heart and Stroke NetworkEmail: [email protected]

Antoinette ScottAssistant Director,Cardiac Services North West LondonCardiac and Stroke NetworkEmail: [email protected]

Jason AntrobusSenior Project Manager,North West London Cardiac and Stroke NetworkEmail: [email protected]

Chrissie BennettService Improvement Manager,Peninsula Heart and Stroke Network,Email: [email protected]

cardiac rehabilitation - national priority projects: lessons and learning one year on

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