transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the...

NHSNHS Improvement

NHS Improvement Heart

Transforming cardiac rehabilitation: celebrating achievementsand sharing the learning from the national projectsHEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Contents

ForewordProfessor Patrick Doherty, National Clinical Leadfor Cardiac Rehabilitation, NHS Improvement

Reflections from the Clinical LeadsProfessor Patrick Doherty, National Clinical Lead, NHSImprovement and Dr Jane Flint, National Clinical Advisor,NHS Improvement

Introduction

Chapters1. UNDERSTAND YOUR SERVICE2. ENGAGE WITH YOUR STAKEHOLDERS3. INVOLVE PATIENTS AND CARERS4. ENLIST CLINICAL LEADERSHIP5. COLLECT,ANALYSE AND MAKE USE OF ROBUST DATA6. SPECIFY YOUR SERVICE REQUIREMENTS7. COMMISSION EFFECTIVELY8. USE RESOURCES WISELY9. COLLABORATE AND NETWORK10. SEE THE BIGGER PICTURE

Achievements and key learning points by site

Contact information for site project managers

Supporting information

The NHS Quality, Innovation, Productivity andPrevention (QIPP) challenge

Next steps in transforming cardiac rehabilitation

NHS Improvement System

Cardiac Rehabilitation National Project Team

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Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects

3

Foreword

www.improvement.nhs.uk/heart

Cardiac rehabilitation (CR) is a vital part ofcaring for patients with heart disease. It is anevidence-based and cost effectiveintervention that reduces future mortalityand morbidity and improves quality of life.

Over the past decade, the Coronary HeartDisease National Service Framework (CHDNSF) and related initiatives have led to asignificant reduction in the rate of prematuredeath from CHD with some clearimprovements in CHD services across thepathway of care. But there are areas,including cardiac rehabilitation, that werenot well positioned to benefit from the initialfront line investment and have developedless quickly than others.

Despite the collaborative and sustainedefforts of a wide range of partners,awareness and uptake of CR remains low.The National Audit of Cardiac Rehabilitation(NACR 2009) identified that on average only38% of heart attack, angioplasty and bypasspatients received cardiac rehabilitation in2007/08 and there are marked geographicalvariations in access to CR services across thecountry. Access for people with differentcardiac conditions (e.g. people with heartfailure) and for various different populations(e.g. women, black and minority ethnicgroups) is also variable. Many existingservices do not meet the minimum standardsand core components set by the BritishAssociation of Cardiac Rehabilitation (BACR)so that the quality of care patients receive is

often sub-optimal. These problems areunderpinned by the fact that funding andcommissioning arrangements for CR arelargely ad hoc in many areas, with CR seenas an ‘optional extra’ rather than a vital partof treatment.

All in all, CR remains part of the ‘unfinishedbusiness’ of the NSF and there is a long wayto go to meet the challenge of providingtimely access to good quality cardiacrehabilitation.

2010 does not mark the end of the CHDNSF’s implementation. Much of what is inthe NSF is as relevant now as it was 10 yearsago, and its approach continues to stand thetest of time. But there is a need to reviewand examine why we have been able tomake such excellent progress in some areasbut not in others - and we need to do this inthe context of the greatest financialchallenge that the NHS has ever faced. Overthe next few years, at the same time ascontinuing to deliver high quality servicesand ensuring areas like cardiac rehabilitationthat have lagged behind are brought up tothe same high standard, the NHS will needto focus firmly on delivering care much moreefficiently.

Over the life of the NSF, the Department ofHealth has been working with NHSImprovement and the cardiac networks tospread good practice and to help increasethe quantity and quality of cardiac

rehabilitation services across the country.Launched in September 2008, the NationalPriority Project identified twelve sites acrossthe country attempting to increase access,equity and uptake to CR throughimplementation of the National Institute forHealth and Clinical Excellence (NICE)recommendations for cardiac rehabilitationand the associated commissioning guidance.This final report celebrates some of their keyachievements, as well as documenting manyof the invaluable learning points that, onceshared, will help others to drive up standardsof care without reinventing the wheel.

Evidence accrued from NHS Improvementand the CR National Priority Projects plusother clinical areas implementing innovationsuggests that the establishment of robustcommissioning arrangements for CR is likelyto result in improved access, uptake,coverage and quality. Hidden inside the 38%average uptake are islands of excellence thathave made huge inroads to offering highquality CR to the majority of patients. Withthis in mind, NHS Improvement has beenworking alongside the StrategicCommissioning Development Unit (SCDU) atthe Department of Health and other keypartners to develop a Commissioning Packfor Cardiac Rehabilitation. In essence, thepack will facilitate more effectivecommissioning of cardiac rehabilitation;ensuring the shape of CR services reflectsbest clinical evidence and use of CRresources are optimal.

I’m delighted that in 2010/11 NHSImprovement is planning to launch a newround of projects to test the utility of theCommissioning Packs in raising both thequality and efficiency of CR services.

The momentum and enthusiasm for CR hasbeen sustained over time by the CHD NSF,NICE guidance, BACR Standards and CoreComponents, National Audit of CR, NHSImprovement Priority Projects and other keydevelopments in the field that havecollectively created an opportunity for largescale improvement in CR services. Theachievements realised so far are testament tothe hard work and commitment of all thosewho work in the field. The challenge ingoing forward will be to maintain theimpetus and sustain improvements so thatwe can build on what we have learnt in theface of fresh challenges and continue todrive up standards and strive for excellencein cardiac rehabilitation.

My thanks to all those who have contributedto delivering these marvelous improvements.

Professor Patrick DohertyNational Clinical Lead for CardiacRehabilitation to NHS Improvement

The NHS Improvement National PriorityProject for Cardiac Rehabilitation (NPP forCR) came out of a long standingcommitment in the NSF for CHD to delivereffective rehabilitation as part of patientcare following a cardiac event orprocedure. In order to implement thiscommitment there was a clear need tooffer national support to local providers,commissioners and cardiac networks todevelop, implement and evaluateinnovative and productive approaches toaddressing national and regional issues oflow uptake and inequalities of access toservices.

There have been twelve projects withinone year of inception of the NPP for CRand all have achieved major positivechanges to their services. The projects,which were supported by a combinationof high quality clinical teams, perceptivecommissioners and strongly committedpatient representatives, have tackledvarying aspects of service delivery or


4 www.improvement.nhs.uk/heart

Reflections from the Clinical Leads

commissioning of new services. This hasculminated in substantial shared learningand experience that has led to majorinnovations in redesigning clinicalpathways and specification developmentplus tangible decreases in waiting timesand improved uptake to services. Therehave been clear lessons learnt aboutimplementing and measuring quality andproductivity initiatives many of which haveled to new and innovative service modelsthat will withstand future servicepressures.

The benefits to patients are also clear inthat projects have delivered greateruptake and equity in provision, enhancedpatient risk assessment and safety and amore flexible approach to service deliveryunderpinned by patient choice.

The projects have been a real success indelivering a measured improvement at achallenging time for NHS services andeveryone who participated should becongratulated!

Professor Patrick DohertyNational Clinical Lead for CardiacRehabilitation to NHS Improvement


5www.improvement.nhs.uk/heart

Our CHD NSF ‘unfinished business’ ofCardiac Rehabilitation (CR) has benefitedfrom National Priority Projects tacklingpathways, commissioning andinequalities, working towards their twoyear achievements herein summarised.

Key learning points from the journey sofar provide essential lessons for Networksand their cardiac rehabilitationprogrammes: engagement of allstakeholders, involvement of patients andcarers, enlisting clinical leadership, andcollaborating and networking so there canbe effective commissioning.

Understanding your service, specifyingand embedding it within the healthcommunity, collecting, analysing andusing data so resources may be usedwisely in the wider picture, are essential intoday’s constrained financial environment.

The National Cardiac Conference in March2010 allowed us to celebrate the reviewof the post Primary PercutaneousCoronary Intervention (PPCI) pathwayfollowing STEMI, there being majorimprovement in the approach torehabilitation of these patients in leadingNetworks. The example of PPCI roll-outcontained within this documentexemplifies the need to commit toimproving referral and uptake to CR in allcardiac pathways.

The encouragement and assessment ofCR development across the EnglishCardiac Networks 2007-2010 has heldsupport of Networks and PCTs being ableto redesign better and sustainableimprovement in patient care at its heart.The Network surveys have revealedNetwork Cardiologist Champions for CRas well as Programme Lead Cardiologists,many appreciating a ‘LeadershipDevelopment’ Day in November 2009.

The principle of conducting a thorough,individualised assessment of cardiacpatents for their rehabilitation andsecondary prevention needs remainscentral and will be further captured withuse of the Commissioning Pack. Evidencefor the value of CR for people with heartfailure is gathering momentum and thepotential for CR to contribute to areduction in occupied bed days andreadmissions will help to demonstrate theQIPP value of investment in CR duringthese challenging times.

Jane Flint BSc MD FRCPNational Clinical Advisor for CardiacRehabilitation to NHS Improvement

Over the past decade, NHSImprovement and its Collaborativepredecessors have been working withNHS organisations and clinical networksto help transform services and deliversustainable improvements across theentire pathway of care in a number ofclinical specialties- most notably cancer,diagnostics, heart, stroke and now lungservices. Working closely with theDepartment of Health, NHSImprovement’s agenda is closely alignedto national priorities and theorganisation plays a key role insupporting the delivery andimplementation of national healthstrategy.

Using tried and tested improvementmethodology in addition to novel andinnovative approaches, NHSImprovement is working with a widerange of partners to test, model,implement and spread the coreimprovements and ‘winning principles’which have been shown to increaseefficiency and drive up quality inpatient care with the aim of makingservices better for patients and staff.



Introduction

The National Priority Project forCardiac Rehabilitation

Launched in September 2008, theNational Priority Project for CardiacRehabilitation (CR) selected nineprojects, comprising 12 NHS sites fromacross the country supported by theCardiac and Stroke Networks, to driveforward improvements in cardiacrehabilitation services. The overall aimof the National Project was to increaseaccess to, equity of provision for, anduptake of CR services for patientshaving heart attack and/ orrevascularisation, in line with theNational Service Framework for CHD. Indoing so, the Project sought to pilotimplementation of the NICErecommendations on cardiacrehabilitation- as outlined in the NICEClinical Guidelines on MI: Secondaryprevention (NICE CG48, 2007)- utilisingthe subsequent NICE CommissioningGuide for CR services (2008).

Co-ordinated by Linda Binder, NationalImprovement Lead for NHSImprovement, and supported byProfessor Patrick Doherty, BACR

chairperson and National Clinical Lead,and Dr Jane Flint, consultantcardiologist and National ClinicalAdvisor, the National Project invitedapplications which focused on:

• Identification and active engagementof eligible CR participants using asystematic and structured approach

• Development of mixed models ofprovision tailored to meet the needsof individual patients

• Relevant rehabilitation for groups lesslikely to access the service such aswomen or ethnic minorities

• Development of exercise componentsdesigned to meet the needs of olderpeople or those with significantco-morbidities

• Joint agreement, planning andcommissioning of services acrosshospital trust, GP practice, PCT andsocial/leisure services and at networkwide level

• Exploration of the feasibility of ageneric rehabilitation modelencompassing other diseasemodalities.

The Project was also keen to ensurethat the following core issues wereaddressed:

• Reducing inequalities• Increasing access to and informationabout CR services

• Engaging patients/carers/families inplanning services

• Workforce and multi-disciplinaryteam approaches.

Published twelve months after thecommencement of the Project inOctober 2009, the interim report onthe Cardiac Rehabilitation NationalPriority Project: Lessons and LearningOne Year On effectively summarisedthe key learning from across all thesites and aimed to share the initialoutputs, outcomes and improvementswith a wider audience.



Building on the ‘One Year On’ reportthis second and final publication hasbeen produced to celebrate successand to highlight the majorachievements across participating sites.In line with the raison d’être of NHSImprovement, Transforming CR:Celebrating Achievements and SharingLearning from the National PriorityProjects aims to extract the key learningpoints from the Project and share themwith a wider, national audience. Indoing so, it endeavours to demonstratehow cardiac rehabilitation services candrive up quality whilst improvingefficiency and achieve alignment withthe overall strategic direction of theNHS.

The development of Transforming CRhas been a collaborative and iterativeprocess. In May this year, project leadsfor each participating site were invitedto attend a telephone ‘interview’ toshare just three headline achievementsfrom their work - a difficult task in itselfgiven the number and quality ofimprovements in CR services across theNational Project - and to detail any keylearning points associated with eachachievement.

These key learning points and theachievements to which they relate havebeen distilled and grouped under aseries of chapter headings, themes orcommon threads, which effectivelyrepresent the main ingredients in therecipe for CR improvement ‘success’across the projects.

As part of NHS Improvement’scommitment to reducing its carbonfootprint, Transforming CR has beendesigned to be read in electronicformat with a limited print run. Inkeeping with this, and in order to sharethe learning in a more concise anduser-friendly manner, the learningpoints and exemplar achievements havebeen stripped down to theirfundamental core and presented in listformat. A summary of achievementsand key learning points can be foundon page 28. Full transcripts of theinterviews with individual project siteleads are available for download atwww.improvement.nhs.uk/heart/cardiacrehabilitation

In addition to the themed chapters,Transforming CR forges links betweenthe improvements listed and therequirement for all NHS services tofocus on quality whilst at the same timeachieving greater efficiency. It outlinesnext steps in transforming CR in termsof the forthcoming CardiacRehabilitation Commissioning Pack andthe next round of National Projectsaimed at testing the utility of the Packin real life settings. Last, but by nomeans least, Transforming CR points toother useful sources of guidance,advice and information, including fullcontact details for each project site.

Generous thanks are extended toeveryone who has contributed toTransforming Cardiac Rehabilitation bysharing experiences, learning,knowledge and guidance.

http://www.improvement.nhs.uk/heart/cardiacrehabilitation

“Understanding your existing service is anessential first step in redesigning processesto make them better for patients and staff”

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Understand Your ServiceImprovement is all about continuallyworking together to improve theexperience and outcomes for patientsand users and looking for other waysto provide health care thatcontinuously improves the way itmeets the needs of those who dependon it and the working lives of the staffwho provide it1.

In order to really get to grips withimprovement, to find out whichimprovements will make the biggestdifference and what benefits can beachieved as a result, it’s reallyimportant to understand where youare now. Examining your currentservice, exploring the environmentand context that it exists in, andgathering insight into patient andstaff experience is an essential firststep in getting to where you want togo and identifying what you need todo to get there.

Full transcripts of interviews withindividual site managers areavailable to download at:www.improvement.nhs.uk/heart/cardiacrehabilitation

1NHS Modernisation Agency (2005) Improvement Leaders’ Guide: Improvement Knowledge and Skills


1. Know your own catchment area and analyse findings in light of this knowledge. Black Country Cardiovascular Network

2. Using the same benchmarking tool across the network ensures consistency of approach across all services and helps to standardise services across the patch. Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

3. Be open to change and recognise that nothing is too precious to review and, if appropriate, change. Challenge yourself and others in the team. Encourage innovationand don’t be afraid to break established ‘rules’ around service provision. Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

4. Assumptions or anecdotal evidence need to be substantiated when looking at for the reasons behind uptake/non-uptake of CR. Explore uptake in detail using geo-mappingand audit data and be prepared to act on the findings. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac and Stroke Network

5. Conducting a comprehensive and rigorous audit to establish a baseline position, help understand if existing services are meeting the required standards, and provide real data to back up any anecdotal evidence is an essential first step for any new project seeking to improve the quality of patient care/ services (and win awards!). Make sure audits are repeated to gauge progress and reset the baseline as improvements are realised. North West London Cardiac and Stroke Network

6. Reviewing services, drawing up a broad strategy underpinned by a comprehensive service specification and obtaining universal acceptance across the health economy is not as straightforward as it may appear. Be prepared to spend a lot of time on the process and supporting documentation, consulting with and incorporating views from all key stakeholders, so that the strategy is comprehensive and meets everyone’s needs. Take every opportunity to win ‘hearts and minds’ – it will pay dividends in the long term. Peninsula Heart and Stroke Network

7. Make the most of any opportunities to stand back from your service and look at what’s really going on. It takes some discipline and it’s not always easy or comfortable but understanding your existing service is an essential first step in redesigning processes to make them better for patients and staff. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network

8. It is essential to include commissioners in the initial review of services and in any plans for future service redesign. Shropshire and Staffordshire Heart and Stroke Network

Key learning points Exemplar achievement: Shropshire and Staffordshire Heart and Stroke NetworkReview of current service provision with options analysis and plans to movetowards a commissioned programme

Background and contextA baseline audit in 2008 to highlight good practice and identify gaps in service indicatedthat a redesign of the CR service in North Staffordshire was required to increase capacityand offer rehabilitation to all eligible patients in both hospital and community settings. The audit demonstrated that for the more significant gaps in regional rehabilitation,service funding plays a major role. Wherever possible cost neutral changes have beenimplemented, yet without additional funding and engagement in primary care, anysubstantial service improvement is impossible.

The cardiac rehabilitation team were keen to begin working on redesign and took theopportunity to visit other centres in the country to look at new ways of working anddevelop prospective plans as discussions with providers and commissioners began.

After a number of discussions with commissioners and the appointment of a cardiacrehabilitation lead manager, an options analysis paper was compiled and the redesignwork has started. It has been agreed that this work should be supported with a view tomoving towards a fully commissioned service. With the development of the cardiacrehabilitation Commissioning Pack the impetus has increased and this programme will be applying to become one of the new implementation sites.


“Invest in real stakeholder engagement at everystage of the process and be prepared to adjustyour ‘sales pitch’ and approach to appeal todifferent audiences”

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Engage with Your StakeholdersStakeholders are those people andgroups who are affected by a projector are important to its success. Thedegree to which stakeholders areengaged will affect the outcome ofany improvement initiative.Stakeholder engagement may takemany forms but is essentially acontinuous process combiningcommunication and involvement fromthe planning stages right through tocompletion.

However, winning the hearts andminds of those with a vested interestin your project is not as simple as itsounds. Successful engagementinvolves recognizing the differentbackgrounds and cultures of thevarious stakeholders, understandingthe ‘what’s in it for them’, and using a variety of different tools andtechniques to hear and listen to theirexperiences and needs.

2NHS Modernisation Agency (2005) Improvement Leaders’ Guide: Leading Improvement

The best approach is to analyse thelevel of support required from eachindividual or stakeholder group andthen direct attention towardsachieving it2.



1. Engage service providers, individual staff groups and people at a senior level at a very early stage. This will lead to earlier acceptance of the need for redesign. Peninsula Heart and Stroke Network

2. Invest in real stakeholder engagement at every stage of the process and be prepared to adjust your ‘sales pitch’ and approach to appeal to different audiences in order to encourage and sustain interest and involvement with different stakeholders.Derbyshire County PCT

3. Be prepared to manage your market. Investing resources in informing and developing potential providers reaps rewards in terms of increasing understanding of the procurement process and the service specification. Derbyshire County PCT

4. Establish good relationships with the local council/ exercise providers so that you can flex the system and provide choice for patients. Derbyshire County PCT

5. Try to engineer a broad spread of stakeholder attendance at national meetings, rotating staff/patient attendance as necessary/relevant in order to stimulate ideas, encourage innovation and maintain a wider perspective.Shropshire and Staffordshire Heart and Stroke Network

6. The provision of a focused workshop which catered specifically to the expressed needs of clinicians and commissioners was essential in securing positive and sustained stakeholder engagement. Bringing clinicians and commissioners together and involving them in the process of developing outcome measures- rather than developing the measures and seeking comments retrospectively- enabled involvement to be viewed as a distinct opportunity. South London Cardiac and Stroke Network

Key learning points Exemplar achievement:

Derbyshire County PCT Effective stakeholder engagement

Background and contextThe CR working group made every effort to involve and consult with all key stakeholdersfrom the outset. The service specification went out to public consultation, as well asbeing presented to the local CHD strategic commissioning group, the Long TermConditions Programme Board and clinicians from primary and secondary care. Patientrepresentatives were involved in the development of the strategy and servicespecification, sat on the Procurement Project Board and were integral to the decision-making process. Their involvement lent credence to the process and far from being atokenistic gesture; patients were fully engaged in the process and able to bring theirvaried and valuable experiences to bear on the outcome.

The recruitment of both an internal and external clinical lead was crucial to thedevelopment of the pathway. The internal clinical lead provided important localknowledge and clinical guidance and leadership. An external clinical lead was viewed asbeing essential in terms of injecting the redesign process with objectivity, enablingcommissioners to make informed decisions and challenge current practice.

As the PCT intended the new CR pathway to bring care closer to home for patients, theinvolvement and engagement of local general practitioners and their primary carecolleagues was crucial. With this in mind, the PCT held a number of consultation eventsfor primary care colleagues on a locality basis, and targeted Practice BasedCommissioning clusters so that they could provide feedback to individual GPs.

As an integral part of the procurement process, the PCT facilitated a ‘provider forum’ forproviders interested in tendering for the new service. The PCT used this opportunity topresent and explore key aspects of the service specification in order to answer anyqueries, challenge any misconceptions, and also to amend the service specification wherenecessary. Moreover, utilising expertise brought in from the national procurement hub,the PCT undertook to speak with all potential providers on an individual basis tostimulate interest in the tender and provide as much information on the servicespecification as possible.


“Listening to the patients’ voice helps to ensureservice redesign is focused around the needs of patients and carers”

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Involve Patients and CarersMeaningful and effective patient andcarer involvement is fundamentallyimportant in every aspect ofimproving health care. Aside frombeing a basic right, greaterinvolvement of patients, carers andthe public in planning and deliveringhealthcare is likely to result in betterquality services that are moreresponsive to the needs of patients,leading to better outcomes. Policy and planning decisions are likely to be more patient-focused and

communications betweencommissioners and providers and the communities they serve will beimproved. Overall, real patient andcarer involvement and engagementwill lead to greater ownership andunderstanding of local health servicesand why and how they need tochange and develop.

Far from ‘doing to’ or even ‘doing for’ patients, contemporaryapproaches to involvement reachbeyond consultation and focus on

creating genuine, continuous andsustainable partnerships where all thepeople involved are acknowledged ashaving a unique and importantcontribution and are respected asequals3.

3NHS Modernisation Agency (2005) Improvement Leaders’ Guide: Involving Patients and Carers



1. Discovery Interviews should be used for other service user groups such as heart failure or angina patients but also has a wider application across all service provision and clinical specialties. Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

2. Regard patients and carers as equal partners in service redesign and development and provide real opportunities for them to become involved in planning and decision making. Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

3. Establish a transparent and robust system for recruiting patient and carer representatives to ensure that people are as objective as possible and do not pursue their own agenda. Provide patient and carer representatives with appropriate support and training from a qualified and experienced Patient and Public Involvement (PPI) leadto ensure that they are able to contribute in a meaningful way and allow the patient voice to be heard. Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

4. Ensure that appropriate steps are taken to safeguard patient confidentiality when seeking to share patient data or feedback to improve care. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac and Stroke Network

5. Involve patients systematically in service improvement efforts, but understand and takeadvantage of any opportunities to gather feedback on patient experience.North West London Cardiac and Stroke Network

6. If you consider asking patients their opinion via a questionnaire or other method, therehas to be a robust mechanism for feedback of results and then follow up to demonstrate resulting actions.Shropshire and Staffordshire Heart and Stroke Network

7. It’s important to have planned in advance what you are going to do with the information and be prepared to review and alter your service as a result of the information received. Shropshire and Staffordshire Heart and Stroke Network

8. Staff shouldn’t assume they always know what is best in terms of service provision - it’s the patient view that is important! Shropshire and Staffordshire Heart and Stroke Network


Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke NetworkUtilising Discovery Interviews to review and critically analyse the service fromthe patient perspective

Background and contextDiscovery Interviews, originally developed by the CHD Collaborative and utilised bycardiac networks and other areas nationally, are a well evaluated tool for learning about aservice from the patient perspective. Discovery Interviews use a semi-structured interviewtechnique which allows the patient to speak about their experiences in their own words –a very powerful narrative that frequently leads to fundamental changes to services.

In the Dorset Cardiac Network a relevant Discovery Interview transcript is played at thebeginning of meetings in order to allow staff to focus on the patient perspective and toinstigate discussion.

One of the Discovery Interviews prompted all three CR teams across Dorset to hold aprocess mapping event focusing on patient letters, documentation and informationbooklets with patients and staff. This resulted in revision of information to meet theneeds of the patients and helped to increase uptake of CR services – for example, one ofthe revisions to information was to add the phrase ‘Your consultant has recommendedthat you attend cardiac rehabilitation….’- a compelling commendation for many patients.

The information review also facilitated the provision of standardised information andgreater collaboration between centres in the network – particularly betweenBournemouth and Poole, many of whose patients are eligible to attend the CR service ateither hospital. This was particularly relevant where Poole patients attend for angiogramat Bournemouth and then may choose where to attend for rehabilitation. The sameinformation booklet from the catheterisation suite at Bournemouth is now given to allpatients. This has helped prepare patients and carers for the next steps in the carepathway and has helped to reduce anxiety.


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Strong clinical leadership is imperative to obtainbuy-in from key stakeholders in improvementefforts, build a shared vision and support animprovement culture…

Enlist Clinical LeadershipIt is widely acknowledged that strongleadership at all levels in the NHS isrequired to achieve the ambition ofdelivering gold standard health andhealth services to patients andcommunities. There is much evidenceat a national and local level from bothprimary, secondary and tertiary carethat where there is effective clinicalengagement and leadership, theninnovation, modernisation, qualityimprovement and patient-focusedcare flourish. Effective clinical leaders

have the skills and knowledge to leadwith vision and creativity, create aculture of innovation, and help toshape and implement the strategicdirection of health care byhighlighting, influencing,communicating with, respecting andsupporting others. They believe in thetask in hand and the importance ofworking across traditionalorganisational boundaries, whilstensuring a constant focus on patient-centred outcomes.

Although it’s not always easy toobtain, clinical leadership is crucial forthe ownership and sustainability ofservice improvements and ongoingclinical engagement. A significantproportion of all improvementendeavours should be focused onbuilding the capacity for change andinnovation in people andorganisations.



1. Engage with clinical leads from the outset and involve them in every step of the project so that they can share their expertise and experience, win over other clinicians and teams, and steer and implement change. Ensure that other stakeholders and those outside the project understand the network’s facilitative role and that the real improvements are owned and managed by the organisations and individuals that it brings together.North West London Cardiac and Stroke Network

2. Designate a programme leader to each individual programme and give them the responsibility for planning their service.Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network

3. Strong clinical leadership is imperative to obtain buy-in from key stakeholders in improvement efforts, build a shared vision and support an improvement culture- particularly amongst other clinicians and frontline staff. Providers find it reassuring when commissioners see the need for clinical expertise in any review of service or plans for service redesign and feel more confident that their voice will be heard. NHS North of Tyne, North of England Cardiovascular Network


North West London Cardiac and Stroke NetworkThe attainment of strong clinical leadership and good clinical engagement from the outset

Background and contextThe PPCI CR project has two clinical leads, Judith Edwards, the Senior Clinical NurseSpecialist who leads the project at Imperial College Healthcare NHS Trust and Dr AmarjitSethi, a Consultant Cardiologist from Ealing Hospital NHS Trust. Both clinical leads werehighly motivated to address the problem and were comfortable with cross-sectorworking.

Both clinical leads are strongly committed to the development of cardiac rehabilitationacross North West London and keen to facilitate uptake of CR by any means within theirscope. They meet regularly with the CR service improvement manager for North WestLondon Cardiac and Stroke Network to review progress and discuss future plans forservice development, demonstrating a proactive approach in identifying new ideas orsolutions to any issues arising.

The network hosts a Cardiac Rehabilitation Working Group. Judith Edwards and DrAmarjit Sethi are actively involved in formulating and agreeing the agenda for themeetings, preparation of meeting papers, agreeing actions arising and monitoring results.Both of them attend the meetings and can be approached at any time.

Without their strong commitment and motivation, working with the CR group, theservice improvement manager and with staff ‘on the ground’, the project would not haveachieved the level of change and the sustained achievements it has demonstrated todate.


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Use robust data to provide evidence to underpinthe need for service redesign and to demonstrateachievements”Collect, Analyse and Make Use of Robust DataCapturing, interpreting and utilisinggood quality data is an essentialelement in planning, implementingand evaluating the success of anyimprovement project. Although ‘data’and ‘information’ are often usedinterchangeably, data is effectively rawmaterials and unorganised facts thatwhen processed, organised andstructured and placed in context theybecome useful ‘information’. Data canhelp you diagnose and define your

problem, focus your improvementefforts, mobilise support andresources and demonstrate if theresources, time and energy invested in any improvement work representsvalue for money. Most importantly,when linked to the aims andobjectives of a project or service, it will enable you to understand,demonstrate and measure whetherany change has resulted in animprovement, the scale of theimprovement, and whether it’ssustainable.

Most improvement projects involve acombination of qualitative andquantitative approaches. This allowsstatistically reliable informationobtained from numericalmeasurement to be backed up by and enriched by more in-depthinformation about the experience ofgroups and individuals.



1. A pilot of audit questions is imperative in order to check whether you are asking the right questions in the right way, otherwise you will not get comprehensive answers and the answers you do receive may be misleading. Black Country Cardiovascular Network

2. It is essential to have good quality data to be able to fully understand and analyse a service. Black Country Cardiovascular Network

3. Conducting a comprehensive and rigorous audit to establish a baseline position, help understand if existing services are meeting the required standards, and provide real data to back up any anecdotal evidence is an essential first step for any new project seeking to improve the quality of patient care/ services (and win awards!). Make sure audits are repeated to gauge progress and reset the baseline as improvements are realised. North West London Cardiac and Stroke Network

4. Use robust data to provide evidence to underpin the need for service redesign and to demonstrate achievements. Be prepared to present these data in different ways to meet the needs and priorities of different stakeholders. Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

5. Use all available data to understand where you are now, to provide evidence of the achievement of standards, to monitor progress and to measure service improvement. Data should cover process, payments, activity and outcomes and be able to demonstrate return on investment and secure continued funding. Ensure that all relevant indicators and measures are built into your service specification from the outset and embedded in your service redesign efforts. Derbyshire County PCT

6. Build sustainability into the service by understanding demand and capacity. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network

7. Understanding and collecting data is a vital component of service improvement and redesign in order to establish a baseline and benchmark services, measure progress, manage performance and avoid under-reporting. It is worth investing time and resource in ensuring that everyone recognises the need for robust data and the systems to support data collection, analysis and submission. NHS North of Tyne, North of England Cardiovascular Network

8. Consider local data requirements – you may need to establish your own dataset to useconcurrently with the NACR database depending on how you intend to use the data. NHS North of Tyne, North of England Cardiovascular Network


Black Country Cardiovascular Network Pilot of a three month audit to ascertain why patients were not attending forrehabilitation enabled further development and refinement of questions prior toa more comprehensive nine month audit

Background and contextConcern had been expressed by organisations providing cardiac rehabilitation (CR)throughout the Black Country Cardiac Network (BCCN) that the national picture foruptake of CR was not truly reflective of their experience. In addition they were aware of,and wishing to comply with, the national emphasis to increase uptake to CR. In particularthey wanted to test out the difference between patients being offered, and thendeclining CR, as opposed to CR not being offered and the reasons behind this.

The BCCN had already committed to the three month audit when the opportunity to jointhe national project arose. Joining the national project gave an impetus to the audit,allowing it to develop a more robust outlook, incorporating and increasing measures notpreviously considered and raising the profile of CR in the health community. They saw thewhole process as a means of informing commissioners about the current state of CR inthe BCCN and steps being taken to address any issues.

Statistical analysis was undertaken at the end of the initial three month audit.This demonstrated a huge difference between patients not being referred to the servicein the first place as opposed to being offered the service and then declining. It becameclear during the analysis that some of the paperwork indicated a non-referral when inreality, it was an agreement between the referring health care professional and thepatient that they shouldn’t be referred for what was often the perception that physicalcapacity to exercise precluded referral eg severe arthritis. This bears out a generalmisconception amongst some referrers that CR is ‘just about exercise’ rather than lifestyleinterventions and advice – which would also include some help with full exerciseprogrammes or adapted exercise according to need.

Additional findings, which helped to further develop and refine the questions for the ninemonth audit, were around travel, uptake of female patients to CR and a need to clarifyand add in subsequent questions to the response ‘not interested’ in returns by referrers.When analysing the statistical data it was apparent that this had to be done in context ofknowledge of the local catchment area in order to make the results meaningful.

Initial findings from the nine month audit, which is due to complete in May 2010, alreadyshow improved referral and better data quality. A full and comprehensive review of thedata once the audit is complete will enable the service to be reviewed and furtherdeveloped.


“Be prepared to invest considerable time and resourcesinto the development of a robust and comprehensiveservice specification which effectively captures allneeds and requirements”

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Specify Your Service RequirementsA specification is a documentdescribing a commissioner’s needs,which enables providers to propose anappropriately costed solution to meetthose needs. As a minimum,specifications should set out thecommissioner’s requirements, providea shared understanding of eachparty’s responsibilities and reflectusers’ views.

The effort and resources required todevelop a specification will depend onthe value, complexity and risk of anyprocurement but should not beunderestimated.

Experience suggests that you will getwhat you ask for in the specification:Errors in writing the specification mayaffect end users and undermine yourstrategic aims. Conversely, omittinginformation may lead to assumptionsby the providers which may or maynot be correct. A specification will alsodetermine whether you achieve valuefor money: Over-specifying may resultin paying over the odds and runs therisk of stifling innovation by restrictingprovider flexibility. On the other hand,under-specifying may result inexpensive renegotiations of thecontract or delays in completion.

The preferred option for mostspecifications is to expressrequirements as outcomes, i.e. whatyou are aiming to achieve, rather thaninputs or outputs. Although someoutcomes may be intangible and moredifficult to measure, an outcomes-based specification allows providersgreater flexibility to propose how theywill meet the outcomes and is likely toelicit more innovative provisiontailored to the needs of service usersand local communities4.

Before signing off the specification, it’sworth asking the question, ‘If everythingwe asked for was provided, would wehave what we are really looking for’5?

4Institute for Innovation and Improvement: Commissioning for Patient Pathways5Department for Children, Schools and Families (2009): Procurement Document 7: Specification Writing


1. Reviewing services, drawing up a broad strategy underpinned by a comprehensive service specification and obtaining universal acceptance across the health economy is not as straightforward as it may appear. Be prepared to spend a lot of time on the process and supporting documentation, consulting with and incorporating views from all key stakeholders, so that the strategy is comprehensive and meets everyone’s needs. Take every opportunity to win ‘hearts and minds’ – it will pay dividends in the long term. Peninsula Heart and Stroke Network

2. Be prepared to invest considerable time and resources into the development of a robust and comprehensive service specification which effectively captures all needs and requirements. Peninsula Heart and Stroke Network

3. Establish and maintain robust systems for communication between commissioners andproviders to reduce anxieties and ambiguities in service specification development. NHS North of Tyne, North of England Cardiovascular Network


Peninsula Heart and Stroke NetworkThe development of a new service model and detailed service specification forcardiac rehabilitation, supported by all PCTs across the South West Peninsula.

Background and contextAs with many areas across the country and despite the publication of the evidence, therehas always been patchy development of CR services both nationally and across the SWPeninsula. This is chiefly due to the fact that funds were subsumed by more pressing CHDpriorities such as the achievement of hard targets associated with revascularisation. Atthis time there was no national tariff for CR making it difficult to understand the costingimplications. Furthermore, few NHS organisations have developed tight commissioningspecifications for CR or have audit data enabling them to understand the exact cost ofCR and what value is being delivered for their investment.

As a consequence, services were not given sufficient funding and appropriate resources.Some providers became understandably protective of their services preventing innovativeways of delivering menu based CR - a similar pattern to that across many areas of England.

Despite considerable goodwill from CR expertise in the established CR services, it wasclear that finding more creative ways of ensuring equitable access to CR was vital tosecure appropriate commissioning of services.

In direct response to the acknowledged inequity of CR service provision across theStrategic Health Authority area and a genuine desire to improve local CR services,commissioners asked the network to provide recommendations and a service model forcommissioning future CR services.

The resulting report and recommendations propose a new and innovative service modelof CR with a vision to establish strong links with the broader public health preventionprogrammes (i.e. NHS Health Check) and the long-term conditions agenda. This will help to:1) Ensure services are commissioned in a co-ordinated manner and relevant schemes

are integrated. 2) Expand the range and choice of CR services through a comprehensive risk assessment

ensuring patients receive an individual menu based service. 3) Prevent patients receiving duplication of services which overlap with the management

of other diseases.

A Peninsula wide service specification has been ratified by commissioners with agreed keyperformance indicators (KPIs) and quality markers to ensure equity of services and valuefor money will be achieved.


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It is essential to include commissioners in the initialreview of services and in any plans for futureservice redesign”Commission EffectivelyIn simple terms, commissioning is theprocess by which local organisationsdecide how to spend available fundsto ensure that the health and careservices provided effectively meet theneeds of the population and deliverbetter outcomes for patients based onlocal priorities.

Commissioning is not just aboutprocuring products and services; it’s amore complex process which involvesa broader range of separate but

interlinked activities ranging fromassessing population needs andprioritising health outcomes andinvestment, to developing, stimulatingand managing markets and serviceproviders. In this respect it isincumbent on commissioners as localleaders of the NHS to workcollaboratively with a wide range ofpartners both within and outside theNHS to commission services thatoptimise health gains and reductionsin health inequalities as well asproviding value for money.

In doing so, commissioners areexpected to proactively seek and buildcontinuous and meaningfulengagement with the public andpatients to shape services and improvehealth and with clinicians to informstrategy, and drive quality, servicedesign and intelligent resourceutilisation6.


6www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Worldclasscommissioning


1. Explore opportunities to promote and seek innovation in commissioning and the provision of CR services from the full range of providers (NHS and non-NHS). Peninsula Heart and Stroke Network

2. Work very closely with Commissioners from the beginning and be sure that you are meeting their aims as well. Peninsula Heart and Stroke Network

3. Be prepared to manage your market. Investing resources in informing and developing potential providers reaps rewards in terms of increasing understanding of the procurement process and the service specification. Peninsula Heart and Stroke Network

4. Establish and maintain mechanisms to encourage continuous dialogue between commissioners and providers and ensure this happens right from the outset. If this process is not in place or there are delays in commencing regular meetings, anxieties may surface which then take time to resolve. NHS North of Tyne, North of England Cardiovascular Network

5. Commissioners need to understand the current service in order to develop ideas for a new service. Transparency, an understanding of and willingness to work with providershelps to build and sustain active engagement in the change process. NHS North of Tyne, North of England Cardiovascular Network

6. It is essential to include commissioners in the initial review of services and in any plans for future service redesign.Shropshire and Staffordshire Heart and Stroke Network

7. Make sure that everyone is aware of what is on the horizon and be alert to how embarking on procurement might affect the involvement of stakeholders. Half way in to the procurement process in Derbyshire the PCT became aware of potential conflicts of interest with clinicians and managers from provider Trusts already engaged in the service redesign efforts. This highlighted the importance of the need to be prepared tomanage relationships in a different way whilst maintaining the enthusiasm and commitment of key stakeholders in pathway redesign. Derbyshire County PCT


South London Cardiac and Stroke NetworkThe development of a set of core commissioning outcomes for cardiacrehabilitation (CR) at a pan-London level

Background and contextThe network identified that clinicians lacked a sound understanding of thecommissioning process for CR and also that commissioners did not fully understandoutcomes for cardiac rehabilitation. Moreover, there was no common approach tocommissioning for CR across the sector and that this was common throughout allLondon networks.

In view of this, the network organised and facilitated a pan-London event forcommissioners and clinicians. The primary purpose of the workshop was to engage withclinical and commissioning colleagues in the development of a common set of coreoutcomes to be used when commissioning CR.

The event was very well-received and generated a great deal of positive feedback fromcommissioners and clinicians alike.

The core outcome measures- which are now in their third and hopefully final draft- focuson quality of life, patient goals and patient satisfaction. Stakeholders have agreed that CRprogrammes across the patch must show evidence of benefit in all three measures.

As part of the process, local clinicians suggested that there would be benefit frombenchmarking patient satisfaction/ experience across the patch. With this in mind, apatient experience questionnaire is currently being developed by and for CR patients. Thisfits in well with the quality strand of the QIPP agenda.

In addition to the successful identification of core pan-London outcome measures for CR,the workshop also highlighted the lack of formal learning opportunities for CR staffwithin the Network. In view of this, the Network is planning to hold a similar pan-Londonevent on an annual basis, as well as regular educational sessions for CR teams at anetwork level.

The network is also hoping to incorporate the local measures into the National Audit ofCardiac Rehabilitation (NACR), though the current inability to produce a Network-levelreport is seen as a risk to delivery.


“Don’t duplicate systems and/or services - find out what is already available, whether public or privatelyprovided, and forge links where appropriate”

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Use Resources WiselyWhile the economic landscape aroundus has changed dramatically in recentmonths, the vision for an NHS withquality at its heart remains the same.Far from being an accessoryprogramme, the Quality, Innovation,Productivity and Prevention (QIPP)agenda has created a new backdropfor the NHS and has led to a greaterfocus on efficiency, productivity,quality and value.

Delivering improvements in aresource-constrained environmentrequires an even bigger emphasis on

eliminating waste, more effectivepartnership working and the pursuitof evidence-based practice. Asdiscussed later in this document, it isnow more important than ever toensure the use of NHS resources isgeared towards providing clinicallyeffective and high quality care,delivering value for money and betterand sustainable outcomes for localpeople. NHS organisations can achievethis not only through prudentfinancial management, strategiccommissioning and good governance,but also through shrewd managementof people, assets and other resources.

Innovation and service redesign inparticular- along with prevention- areviewed as being key enablers forachieving quality and productivitygains and improving outcomes andefficiency in health. The key principlesof service redesign in this respectcomprise a focus on the patientjourney and improving patientexperience and outcomesaccompanied by meaningfulinvolvement and engagement of allkey stakeholders, including clinicians,managers and patients. Service


redesign efforts should follow astructured methodology but, moreimportantly, should be clinically ledand promote effective team working.


1. Consider using training to increase skills in marketing techniques so that patients and referrers fully understand the benefit of undertaking a rehabilitation course. Black Country Cardiovascular Network

2. Providing sufficient time to train staff and allow them to adjust to a new system is vital, but the rewards in terms of information and patient management are almost instantaneous. Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

3. Ensure that staff are afforded sufficient time to devote to discussing and agreeing individual management plans with patients and responding to their individual needs and preferences. Although this can be time consuming at the outset, the amount of time spent can be reduced with experience and pays huge dividends in terms of improving patient experience and the quality of patient care, as well as improving overall service efficiency. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac and Stroke Network

4. Investigate interventions and services aimed at tackling health inequalities and improving health in deprived areas as these may help identify other potential sources of funding. Peninsula Heart and Stroke Network

5. Don’t duplicate systems and/ or services – find out what is already available whether public or privately provided, and forge links where appropriate.Peninsula Heart and Stroke Network

6. As a project manager be focussed on what it is you are trying to achieve – be clear about your role and the role of others you are working with to achieve redesign. Peninsula Heart and Stroke Network

7. Consider all eventualities and think about how to deal with any findings uncovered during apilot phase. In this case, the skills competency audit identified some unexpected clinical governance issues which could not be discussed further without compromising the confidentiality of staff involved in the pilot. By providing each audit participant with a personal summary report/ audit feedback, the individuals concerned were able to raise training and development needs in the context of personal performance reviews. South London Cardiac and Stroke Network

8. Establish good relationships with the local council/ exercise providers so that you can flex the system and provide choice for patients. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network

9. Timetable weekly communication meetings for all team members to discuss issues and propose solutions.Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network


Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North EastYorkshire and North Lincolnshire Cardiac and Stroke NetworkPatients no longer have to wait to join the phase three CR programme in thehospital or community

Background and contextIn an effort to tackle the historical three month long waiting time, and to ensure thatpatients received timely and appropriate access through triage to phase three CR, the CRteam worked alongside the local cardiac network to map the existing service andundertake a demand and capacity exercise.

Process mapping identified that the major bottleneck in the process was the need forpatients to attend clinic appointments so that doctors could make an assessment on thepatient ensuring they were fit to commence the CR programme. In some cases, patientswere waiting several months to be seen before being deemed fit to commence phasethree CR, and then being referred back to the CR service. The team also identified thatclinic appointments and CR sessions were often cancelled due to Bank Holidays, studydays and so on.

In view of the findings, the team redesigned the service. Instead of waiting for a clinicappointment, patients are now given a pre-assessment appointment within two weeks ofbeing considered fit to commence phase three. At pre-assessment, patients are assessedby the nurses and the exercise instructor, and if deemed suitable are given a definitivestart date for phase three - usually within a week but sometimes the next day! Anypatients deemed unsuitable at pre-assessment are given a clinic appointment prior tocommencing the exercise programme and/or CR, staff are given the opportunity todiscuss the case with the consultant.

Work is now planned to mitigate the effect Bank Holidays have on the service and thereis a strict ‘no cancellation’ policy coupled with a greater focus on forward planning.Patients are also encouraged to take more responsibility for their rehabilitation - sessionsmissed for any reasons other than ill-health are no longer ‘tagged on’ to the end of theprogramme. Patients have responded well to this and take responsibility for their ownrehabilitation, ensuring they attend their planned sessions and exercising up to five timesa week on their own according to recommended guidelines.

Partnership working with the local council and exercise instructors and conducting caseconferences with the multi-disciplinary team on a weekly basis has enabled the service tofast track suitable patients into phase four rehabilitation, releasing capacity for the phasethree course.


“The National Priorities Project has been an opportunityto network and share information with other cardiacrehabilitation centres locally and nationally to promote best practice”

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Collaborate and NetworkThe vision for the NHS in England isone in which patients and the publicare enabled to become active partnersand not just passive recipients of care.This, in turn involves the activeengagement of staff and collaborationacross the NHS and partnerorganisations.

Networks- formal or informal- haveimmense potential to improve the waythat services are planned,commissioned and delivered for bothstaff and patients. Bringing togetherclinicians, managers and

commissioners they allow individualsto step outside traditionalorganisational, cultural, political andgeographical boundaries and work ina co-ordinated manner to ensureequitable provision of high-quality,clinically effective services. Networksplay a key role in fostering innovationand bring in ideas from other areasand initiatives to support serviceimprovement and redesign and indoing so can help the NHS spread andsustain effective concepts,improvement ideas and processes forthe common good. Most importantly,networks can provide a powerful

voice in the local health economy toenable frontline staff to secure thechanges they need to deliver for theirpatients.

By making both formal and informalnetworks visible, managers cansystematically assess and supportstrategically important collaboration.



1. Make the most of every opportunity to become involved in discussions across the PCT and wider network. Be proactive and don’t just accept the status quo. Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

2. Working collaboratively pays dividends in terms of cross-pollination of knowledge and skills.It may not be feasible or desirable to offer exactly the same CR service at different sites and in different localities but it is possible to work towards achieving the same high standards of care.The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac and Stroke Network

3. Spend time - as a team - thinking through processes and patient pathways and establishing cause and effect before taking action. Not all cardiac rehabilitation services are created equally and although it’s possible to work together to reach the same high standards and achieve the same improvement goals the root causes, problems and solutions may differ from site to site.North West London Cardiac and Stroke Network

4. Plan dates for workshops well in advance - essential if you want to be as inclusive as possible and recognise and give consideration to the pressures that frontline services are under.NHS North of Tyne, North of England Cardiovascular Network

5. Hold local meetings, or devise other ways of rapid feedback locally, while the learning and discussions held at national level are still fresh and pertinent – this reduces ambiguity and discord and maximises the potential for shared learning, idea development and action.Shropshire and Staffordshire Heart and Stroke Network


Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke NetworkTeamwork and pan-network working, learning and sharing enabled the CR teamto think ‘outside the box’ with service redesign

Background and contextThe population of Dorset is served by three Acute Trusts: The Royal Bournemouth NHSFoundation Trust, Poole Hospital NHS Foundation Trust and Dorset County Hospital NHSFoundation Trust. All three hospitals provide CR programmes, but historically these havevaried in length, content and place of delivery to meet local need. Dorset County Hospitalin the west of the county serves a largely rural population and offers phase threeprogrammes in four community sites.

In an effort to ensure that the residents of Dorset are offered equitable CR services of aconsistently high quality, the Network established a Dorset-wide cardiac rehabilitationsub-group to promote joint working and encourage greater sharing and learning acrossthe patch with an initial aim to commission a service which met the BACR guidelines, andwas equitable across Dorset.

The sub-group members include clinicians, commissioners, local authority, cardiacnetwork team and patient and carer representatives.

In order to fully understand the current state of CR services in Dorset, the team at DorsetCounty worked with members of the network sub-group and colleagues across Dorset toprovide a baseline assessment of existing services and to benchmark services against theBACR Standards and Core Components.

Aside from the various CR programmes across Dorset being afforded the opportunity tolearn from each other, the team from West Dorset benefitted particularly from being ableto come together with clinicians and commissioners and to meet and understand localdecision-makers within the PCT and the wider network. This has enabled the team to seethe ‘bigger picture’ and to review their service in light of future plans and priorities forthe PCT and the network as a whole.


“Create strong links to other drivers for change”1100.. SSEEEE TTHHEE BBIIGGGGEERR PPIICCTTUURREE


Make sure that everyone is awareof what is on the horizon

Be aware oflocal politics

“”

See the Bigger PictureAny organisation or service needs toanticipate and respond to the currentand future needs of all keystakeholders, as well as payingattention to the economic, politicaland social environment in which itexists. This means that day to dayoperations, services and improvementprojects need to be aligned with thestrategic vision- or the ‘where wewant to be’ of the organisation orservice. Strategic alignment- seeingand responding to the bigger picture-will effectively ensure that projectsand services deliver the right outputs

at the right time so that resources are used to best effect and theorganisation or service moves in the right direction7.

Although not all service improvementprojects will come from the top of theorganisation where high levelobjectives are set, only those initiativesthat deliver real benefits, meetdefined business needs and are firmlybased in organisational strategy arelikely to be successful and sustainable.Any improvement project, whether itis mandated from the top or not-must be justifiable in terms of cost,

benefits (the outcome of a changethat has some value for one/ some/ allof the stakeholders) and risks(something that might happen tohinder or even stop you achieving theimprovements you’re aiming for) andthese need to be clearly articulatedfrom the outset.


“ ”

7National Diabetes Support team (2008) Diabetes Service Planning: A Project Management Guide


1. Create strong links to other drivers for change including other local and national strategy, policy and guidance, e.g. long term condition management, NHS Health Check in order to increase the efficiency and financial viability of services. Peninsula Heart and Stroke Network

2. Make an effort to see the bigger picture. It is important to listen to the 30% who are happy with existing services but don’t forget to focus your redesign efforts on understanding and meeting the needs of the 70% who do not attend and this may involve doing things differently and being innovative in the service you commission. Derbyshire County PCT

3. Make sure that everyone is aware of what is on the horizon and be alert to how embarking on procurement might affect the involvement of stakeholders. Half way in to the procurement process in Derbyshire the PCT became aware of potential conflicts of interest with clinicians and managers from provider Trusts already engaged in the service redesign efforts. This highlighted the importance of the need to be prepared to manage relationships in a different way whilst maintaining the enthusiasm and commitment of key stakeholders in pathway redesign. Derbyshire County PCT

4. Be aware of local politics and keep abreast of what’s going on around you so that you can take advantage of any opportunities that present themselves.Shropshire and Staffordshire Heart and Stroke Network

5. Find out about different service models by taking the time to see what’s going on outside existing geographical (and cultural) boundaries. For example, a site visit to the CR service at Charing Cross Hospital by the project team was a turning point in the redesign of the Derbyshire County service and was just one method of investigating good practice examples from across the country. Being a part of the National Priority Project was of enormous benefit in this process as it helped to facilitate discussions with colleagues from around the country.Derbyshire County PCT


Peninsula Heart and Stroke NetworkUsing the Peninsula-wide service model to redesign cardiac rehabilitationservices in Cornwall

Background and contextA review of CR services across Cornwall highlighted that CR was not available for alleligible groups and, indeed, that up to 50% of cardiac patients were not being offered orreceiving CR. In the absence of a strategic approach a range of different services hadevolved initially from different sources of funding. This had led to inequity of serviceprovision and a lack of standardisation across the area.

In an effort to improve CR services locally and to deliver to all eligible groups, the serviceimprovement manager and commissioner developed and submitted a business case tothe Performance and Delivery Board in the PCT outlining some options to provideadditional resources and also to redesign the community cardiology service. The firstsubmission was not approved on the basis of cost with the advice that any furthersubmission would need to show that any new service would either be cost-saving or, atthe very least, cost neutral.

The community cardiology business case was enhanced to include elements of Chapter 8NSF (management of atrial fibrillation) and to assist with Quality Marker 2 of the StrokeStrategy (the reduction of stroke risk in people with Atrial Fibrillation). The business caseincluded the appointment of two additional cardiac nurses, to work with acute,community and primary care providers to ensure the appropriate management of thesepatients and hence a potential reduction in the incidence of strokes in the county. Byincorporating these elements the business case was at the least cost neutral with thepotential to be cost saving.

The business case has now been approved. Further work with the service provider forcommunity services has enabled a move away from specialist roles e.g. heart failure,rehabilitation and arrhythmia nurses to a more generic cardiac nursing role, At present areview of nursing skills and competencies is underway to ensure that the needs of allcardiac patients can be met. A full service redesign is now in progress.

The aim is to ensure that all eligible patients receive a cardiac rehabilitation service andthat people with atrial fibrillation are managed appropriately hence reducing theincidence of stroke.


Key Achievement 1: Pilot of a three month audit to ascertain why patientswere not attending for rehabilitation enabled further development andrefinement of questions prior to a more comprehensive nine month audit.



Achievements and key learning points by site

Black Country Cardiovascular Network

Key Learning Points1. A pilot of audit questions is imperative in order to check whether you are

asking the right questions in the right way, otherwise you will not get comprehensive answers and the answers you do receive may be misleading.

2. It is essential to have good quality data to be able to fully understand and analyse a service.

3. Know your own catchment area and analyse findings in light of this knowledge.

4. Never take for granted that referrers know exactly what you offer as a service. Develop strong communication links to update and educate healthcare professionals, revisiting care pathways regularly and adjusting as required. Always communicate any changes to service promptly, using the widest possible circulation, and check understanding.

Key Achievement 2: Educating health care professionals to understand and‘sell’ the benefits of cardiac rehabilitation to patients, using external expertisein marketing techniques, in order to increase uptake and compliance.

Key Learning Point1. Consider using training to increase skills in marketing techniques so that

patients and referrers fully understand the benefit of undertaking a rehabilitation course.

Key Achievement 1: Assessing and benchmarking existing CR services inDorset against the BACR Standards and Core Components in order toimprove and standardise care across the network.

Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

Key Learning Points1. The assessment and benchmarking exercise allowed the team to

understand that they were providing a good service, but also identified areas for improvement.

2. Using the same benchmarking tool across the Network ensured consistency of approach across all services in the County and helped to standardise services across the patch.

3. Communicating with each individual member of the team was important in order to help staff understand why they were undertaking the benchmarking exercise and identify the direction of travel of the service.

Key Achievement 2: Obtaining Cardiac Network funding to purchase theTomcat Cardiovascular Information Management System to improve audit ofthe CR service.

Key Learning Points1. It was enormously important to identify one person from the team as a

data lead to ensure successful implementation of the Tomcat system and to train other team members in the system usage.

2. Providing sufficient time to train staff and allow them to adjust to the newsystem was vital, but the rewards in terms of information and patient management were almost instantaneous.

Full transcripts of interviews with individual project site managers are availablefor download at www.improvement.nhs.uk/heart/cardiacrehabilitation


Key Achievement 3: Utilising Discovery Interviews to review and criticallyanalyse the CR service from the patient perspective.

Key Learning Points1. Plan to undertake and play Discovery Interviews on a regular basis to assist

in review and further development of CR services.2. Discovery Interviews should be used for other service user groups such as

heart failure or angina patients but we should recognise that the DiscoveryInterview technique has a wider application across all service provision andclinical specialties.

Key Achievement 1: Teamwork and pan-network working, learning andsharing enabled the CR team to think ‘outside the box’ with service redesign.

Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network

Key Learning Points1. Make the most of every opportunity to become involved in discussions

across the PCT and wider network. Be proactive and don’t just accept the status quo.

2. Use robust data to provide evidence to underpin the need for service redesign and to demonstrate improvements. Be prepared to present these data in different ways to meet the needs and priorities of different stakeholders.

3. Don’t get frustrated if change takes a while to engineer. Making changes can be difficult and challenging. Take the time to establish robust systems for collecting good quality audit data.

Key Achievement 2: Listening to the patient’s voice helped to ensure serviceredesign is focused around the needs of patients and carers.

Key Learning Points1. Regard patients and carers as equal partners in service redesign and

development and provide real opportunities for them to become involved in planning and decision-making.

2. Establish a transparent and robust system for recruiting patient and carer representatives to ensure that people are as objective as possible and do not pursue their own agenda. Provide patient and carer representatives with appropriate support and training from a qualified and experienced Patient and Public Involvement (PPI) lead to ensure that patients and carersare able to contribute in a meaningful way and the patient voice is heard and understood.

Key Achievement 3: Using baseline audit to identify and understanddifferences in service provision and levels of uptake across a network area.

Key Learning Points1. Be open to change and recognise that nothing is too precious to review

and, if appropriate, change. Challenge yourself and others in the team. Encourage innovation and don’t be afraid to break established ‘rules’ around service provision.

2. Understand that CR services may differ for legitimate reasons but that it is possible to provide an equitable service and to strive for and achieve the same consistently high standards.



Key Achievement 1: A mutually agreed management plan is now given toMyocardial Infarction (MI) and Percutaneous Coronary Intervention (PCI)patients.

The Royal Bournemouth and Christchurch Hospitals NHS FoundationTrust, Dorset Cardiac and Stroke Network

Key Learning Point1. Ensure that staff are afforded sufficient time to devote to discussing and

agreeing individual management plans with patients and responding to their individual needs and preferences. Although this can be time consuming at the outset, the amount of time spent can be reduced with experience and pays huge dividends in terms of improving patient experience and the quality of patient care, as well as improving overall service efficiency.

Key Achievement 2: Local geo-mapping and survey data helped the CRteam in Bournemouth to plan service expansion more effectively.

Key Learning Points1. Assumptions or anecdotal evidence need to be substantiated when

looking at for the reasons behind uptake/non-uptake of CR. Explore uptake in detail using geo-mapping and audit data and be prepared to acton the findings.

2. Be prepared to pilot different approaches to providing CR in order to ensure services are equitable and respond to patient choice.

3. Working collaboratively pays dividends in terms of cross-pollination of knowledge and skills. It may not be feasible or desirable to offer exactly the same CR service at different sites and in different localities but it is possible to work towards achieving the same high standards of care.



Key Achievement 3: Following up patients at 12 months and sharing theoutcomes with practice nurses has helped to improve long term patient care.

Key Learning Points1. Use data and seek hard evidence to assess ongoing patient needs. People

may need different amounts of support and for a much longer period of time than professionals assume.

2. Ensure that appropriate steps are taken to safeguard patient confidentiality when seeking to share patient data or provide feedback to improve care.



Key Achievement 1: Achieving an award-winning increase in the uptake of CRamong patients receiving Primary Percutaneous Coronary Intervention (PPCI).

North West London Cardiac and Stroke Network

Key Learning Points1. Conducting a comprehensive and rigorous audit to establish a baseline

position, help understand if existing services are meeting the required standards, and to provide real data to back up any anecdotal evidence is an essential first step for any new project seeking to improve the quality ofpatient care/ services (and win awards!). Make sure audits are repeated to gauge progress and reset the baseline as improvements are realised.

2. Set specific, measurable, attainable, realistic and timely goals so the wholeteam can establish what needs to be done to get to where it wants to go, how long it will take to get there, and can ensure that each member of the team is moving in the same direction.

3. Spend time- as a team- thinking through processes and patient pathways and establishing cause and effect before taking action. Not all cardiac rehabilitation services are created equally and although it’s possible to work together to reach the same high standards and achieve the same improvement goals the root causes, problems and solutions may differ from site to site.

Key Achievement 2: The attainment of strong clinical leadership and goodclinical engagement from the outset.

Key Learning Points1. Engage with clinical leads from the outset and involve them in every step

of the project so that they can share their expertise and experience, win over other clinicians and teams, and steer and implement change. Ensure that other stakeholders and those outside the project understand the network’s facilitative role and that the real improvements are owned and managed by the organisations and individuals that the Network brings together.

2. Best practise and lessons learned from the project will be shared with other CR programmes across North West London.

Key Achievement 3: Involving patients in order to improve patient experience.

Key Learning Point1. Involve patients systematically in service improvement efforts, but

understand and take advantage of any opportunities to gather feedback on patient experience.

Key Achievement 1: The development of a new service model and detailedservice specification for cardiac rehabilitation supported by all PCTs across the SouthWest Peninsula.

Peninsula Heart and Stroke Network

Key Learning Points1. Reviewing services, drawing up a broad strategy underpinned by a

comprehensive service specification and obtaining universal acceptance across the health economy is not as straightforward as it may appear. Be prepared to spend a lot of time on the process and supporting documentation, consulting with and incorporating views from all key stakeholders, so that the strategy is comprehensive and meets everyone’s needs. Take every opportunity to win ‘hearts and minds’ – it will pay dividends in the long term.

2. Create strong links to other drivers for change including other local and national strategy, policy and guidance, e.g. long term condition management, NHS Health Check, in order to increase the efficiency and financial viability of services.

3. Investigate interventions and services aimed at tackling health inequalities/ improving health in deprived areas as this may help identify other potentialsources of funding.

Key Achievement 2: Implementation of the new CR service model is beingincorporated into the Commissioning for Quality and Innovation (CQUIN)payment framework (Plymouth PCT) with the possibility of linking to thedelivery of NHS Health Check in the future.

Key Learning Points1. Be prepared for a thorough exploration of the complete range of services

available to support CR to take longer than anticipated.2. Don’t duplicate systems and/ or services – find out what is already

available whether public or privately provided, and forge links where appropriate.

3. Explore opportunities to promote and seek innovation in commissioning and the provision of CR services from the full range of providers (NHS and non-NHS).

Key Achievement 3: Using the Peninsula-wide service model to redesigncardiac rehabilitation services in Cornwall.

Key Learning Points1. Engage service providers, individual staff groups and people at a senior

level in redesign plans at a very early stage. This will lead to earlier acceptance of the need for redesign.

2. As a project manager, focus on what it is you are trying to achieve – be clear about your role and the role of others you are working with to achieve redesign.

3. Be innovative in pulling together a business case, especially in a time of economic down turn.

4. Work very closely with commissioners from the beginning and be sure thatyou are meeting their needs.





Key Achievement 1: The development of a set of core commissioningoutcomes for CR at a pan-London level.

South London Cardiac and Stroke Network

Key Learning Points1. The national projects Cardiac Rehabilitation workshop on health related

outcome measures, facilitated by Steve Callaghan from Liverpool PCT, waspivotal for the network team in gaining an understanding of how outcome measures for the project could be formulated, shared and refinedusing a sector wide approach.

2. The provision of a focused workshop which catered specifically for the expressed needs of clinicians and commissioners was essential in securing positive and sustained stakeholder engagement. Bringing clinicians and commissioners together and involving them in the process of developing outcome measures- rather than developing the measures and seeking comments retrospectively- enabled involvement to be viewed as a distinct opportunity.

3. Difficulties obtaining robust data on CR have made benchmarking, establishing a baseline and setting realistic improvement goals for CR across the area a significant challenge.

Key Achievement 2: The development of a Skills Competency Audit for CR.

Key Achievement 3: Improving access and outcomes with specific target groups.

Key Learning Points1. The implementation of three new services has identified the need to

incorporate effective referral pathways into CR from the respective patient pathways for angina, Implantable Cardioverter Defibrillator (ICD) and heartfailure.

2. The term ‘PDSA’ may have gone out of fashion, but the Plan, Do, Study, Act - pilot then spread approach to improvement really does pay dividendsin terms of improving CR services for people with CHD.

Key Learning Points1. Consider all eventualities and think about how to deal with any findings

uncovered during the pilot phase. In this case, the skills competency audit identified some unexpected clinical governance issues which could not be discussed further without compromising the confidentiality of staff involved in the pilot.

2. By providing each participant in the skills competency audit with a personal summary report/ audit feedback, the individuals concerned were able to raise training and development needs in the context of personal performance reviews.

Key Achievement 1: Remodelling the CR pathway in order to commission aneffective, consistent and equitable CR service across Derbyshire PCT.

Derbyshire County PCT

Key Learning Points1. Find out about different service models by taking the time to see what’s

going on outside existing geographical (and cultural) boundaries. For example, a site visit to the CR service at Charing Cross Hospital by the project team was a turning point in the redesign of the Derbyshire County service and was just one method of investigating good practice examples from across the country. Being a part of the National Priority Project was ofenormous benefit in this process as it helped to facilitate discussions with colleagues from around the country.

2. Allow key stakeholders, including clinicians and commissioners, to becomereally involved and engaged from the outset.

3. Make sure that everyone is aware of what is on the horizon and be alert to how embarking on procurement might affect the involvement of stakeholders. Half way in to the procurement process in Derbyshire the PCT became aware of potential conflicts of interest with clinicians and managers from provider Trusts already engaged in the service redesign efforts. This highlighted the importance of the need to be prepared to manage relationships in a different way whilst maintaining the enthusiasmand commitment of key stakeholders in pathway redesign.

4. Use all available data to understand where you are now, to provide evidence of the achievement of standards, to monitor progress and to measure service improvement. Data should cover process, payments, activity and outcomes and be able to demonstrate return on investment and secure continued funding. Ensure that all relevant indicators and measures are built into your service specification from the outset and embedded in your service redesign efforts.

Key Achievement 2: Aligning the new CR service with World ClassCommissioning competencies in order to procure a best value, quality service.

Key Learning Points1. Be prepared to invest considerable time and resources into the

development of a robust and comprehensive service specification which effectively captures all needs and requirements.

2. Make an effort to see the bigger picture. It is important to listen to the 30% who are happy with existing services but don’t forget to focus your redesign efforts on understanding and meeting the needs of the 70% who do not attend. This may involve doing things differently and being innovative in the service you commission.

Key Achievement 3: Effective stakeholder engagement.

Key Learning Points1. Invest in real stakeholder engagement at every stage of the process and be

prepared to adjust your ‘sales pitch’ and approach to appeal to different audiences in order to encourage and sustain interest and involvement withdifferent stakeholders.

2. Be prepared to manage your market. Investing resources in informing and developing potential providers reaps rewards in terms of increasing understanding of the procurement process and the service specification.





Key Achievement 1: Patients no longer have to wait to join the phase threeCR programme in the hospital or community.

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust,North East Yorkshire and North Lincolnshire Cardiac and StrokeNetwork

Key Learning Points1. Make the most of any opportunities to stand back from your service and

look at what’s really going on. It takes some discipline and it’s not always easy or comfortable but understanding your existing service is an essential first step in redesigning processes to make them better for patients and staff.

2. Build sustainability into the service by understanding demand and capacity.3. Establish good relationships with the local council/ exercise providers so

that you can flex the system and provide choice for patients.

Key Achievement 2: Assigning an individual programme manager to eachprogramme improved co-ordination and planning.

Key Learning Points1. Designate a programme leader to each individual programme and give

them the responsibility for planning their service.2. Timetable weekly communication meetings for all team members to

discuss issues and propose solutions.



Key Achievement 1: Meaningful engagement between commissioners and allcardiac rehabilitation providers across NHS North of Tyne.

North of Tyne, North of England Cardiovascular Network

Key Learning Points1. Establish and maintain mechanisms to encourage continuous dialogue

between commissioners and providers and ensure this happens right from the outset. If this process is not in place or there are delays in commencingregular meetings, anxieties may surface which then take time to resolve.

2. Strong clinical leadership is imperative to obtain buy-in from key stakeholders in improvement efforts, build a shared vision and support an improvement culture- particularly amongst other clinicians and frontline staff. Providers find it reassuring when commissioners see the need for clinical expertise in any review of service or plans for service redesign and feel more confident that their voice will be heard.

Key Achievement 2: Development of a draft standard pathway servicespecification.

Key Learning Points1. Include administrative staff and consider operational processes in any

discussions between commissioners and providers around service development and redesign as these may impact on the change process. A team approach to considering all the processes underpinning a patient pathway fosters a collaborative approach to problem-solving and overcoming challenges and helps to break down cultural and organisational barriers.

Key Achievement 3: Agreeing a standard data set for all of our CR providers.

Key Learning Points1. Understanding and collecting data is a vital component of service

improvement and redesign in order to establish a baseline and benchmark services, measure progress, manage performance and avoid under-reporting. It is worth investing time and resource in ensuring that everyonerecognises the need for robust data and the systems to support data collection, analysis and submission.

2. Consider local data requirements – you may need to establish your own dataset to use concurrently with the NACR database depending on how you intend to use the data.

2. Commissioners need to understand the current service in order to develop ideas for a new service. Transparency, an understanding of and willingness to work with providers helps to build and sustain active engagement in the change process.

3. Establish and maintain robust systems for communication between commissioners and providers to reduce anxieties and ambiguities in servicespecification development.

4. Plan dates for workshops well in advance - essential if you want to be as inclusive as possible and recognise and give consideration to the pressures that frontline services are under.



Key Achievement 1: Meaningful analysis of patient questionnaires producingrelevant outcomes for patients and staff in service provision.

Shropshire and Staffordshire Heart and Stroke Network

Key Learning Points1. If you consider asking patients their opinion via a questionnaire or other

method, there has to be a robust mechanism for feedback of results and then follow up to demonstrate resulting actions.

2. It’s important to have planned in advance what you are going to do with survey information and be prepared to review and alter your service as a result of the information received.

3. Staff shouldn’t assume they always know what is best in terms of service provision – it’s the patient view that is important!

Key Achievement 2: Review of current service provision with optionsanalysis and plans to move towards a commissioned programme.

Key Learning Points1. Try to engineer a broad spread of stakeholder attendance at national

meetings, rotating staff/ patient attendance as necessary/ relevant in order to stimulate ideas, encourage innovation and maintain a wider perspective.

2. Hold local meetings, or devise other ways of rapid feedback locally while the learning and discussions held at national level are still fresh and pertinent. This reduces ambiguity and discord and maximises the potential for shared learning, idea development and action.

Key Learning Points1. It is essential to include commissioners in the initial review of services and

in any plans for future service redesign.2. Utilise staff enthusiasm for change to maintain momentum, ensuring that

you explore all methods to overcome any seemingly impossible obstacles.3. Be aware of local politics and keep abreast of what’s going on around you

so that you can take advantage of any opportunities that present themselves.

4. When planning service redesign, visit beacons of good practice.

Key Achievement 3: Using attendance at national peer support meetings, and the information provided, to invigorate and stimulate discussion at localmeetings to progress change.

Listed below are the leads for each of theprojects cited within this document.Should you require further information onany of the projects, please contact themdirectly via the e-mail addresses supplied.

Black Country CardiovascularNetwork

Ruba MiahService Improvement [email protected]

Russell TipsonNetwork Lead for CRDirector Action [email protected]

Dorset Cardiac and Stroke Network

Linda EverettClinical Lead Cardiac RehabilitationPoole Hospital NHS Foundation [email protected]

Elaine TovellCardiac Rehabilitation Team LeaderDorset County Hospital NHS Foundation [email protected]



Contact information for site project managers

Vicky SieveyClinical Lead, Cardiac RehabilitationThe Royal Bournemouth and ChristchurchHospitals NHS Foundation [email protected]

North West London Cardiac andStroke Network

Farah Irfan-KhanService Improvement Project Manager [email protected]

Antoinette ScottAssistant [email protected]

Peninsula Heart and Stroke Network

Chrissie BennettService Improvement Manager [email protected]

Lorna GeachService Improvement Manager Cardiology and Stroke,NHS Cornwall & Isles of [email protected]

Michelle RoeNetwork ManagerPeninsula Heart and Stroke [email protected]

South London Cardiac and StrokeNetwork

Alice JennerSenior Project Manager [email protected]

Michelle BullSenior Project [email protected]

Derbyshire County PCT

Janet WhiteheadPublic Health [email protected]

North East Yorkshire and NorthLincolnshire Cardiac and StrokeNetwork

Louise BevingtonLead Cardiac Specialist Nurse, Northern Lincolnshire and GooleHospitals NHS Foundation Trust Scunthorpe General [email protected]

NHS North of Tyne, North of EnglandCardiovascular Network

Tara Twigg Service Improvement Officer [email protected]

Shropshire and Staffordshire Heartand Stroke Network

Jane BarnesService Improvement [email protected]



Supporting information

Please note that the following sectioncontains references to organisationsand/or documents that had currencyover the life of the National PriorityProject. Many of these references willcontinue to be of value to cardiacrehabilitation services in movingforward, but it is in no way intended tobe a definitive or exhaustive list.

2010 Evidence Update on CardiacRehabilitationThis Annual Evidence Update from NHSEvidence draws together the evidencefrom systematic reviews and other highquality research and guidancepublished in the past year, building onprevious updates. This evidence hasbeen greatly assisted by the NHSImprovement-Heart CR team andexpert reviewers from the BritishAssociation for Cardiac Rehabilitation.www.library.nhs.uk/CARDIOVASCULAR/ViewResource.aspx?resID=346140

Association of CharteredPhysiotherapists in CardiacRehabilitation (ACPICR)Formed in 1995, the Association ofChartered Physiotherapists in CardiacRehabilitation (ACPICR) is a national

body mainly comprising ofphysiotherapists and otherprofessionals who are working in orinterested in the exercise/physicalactivity components of cardiacrehabilitation. The ACPICR provides, inassociation with the British Associationof Cardiac Rehabilitation (BACR),education via post graduate courses inaddition to publishing standards,competency and peer reviewdocuments to promote and facilitateclinical excellence within its field ofexpertise. www.acpicr.com

British Association for CardiacRehabilitation (BACR) Standardsand Core Components for CardiacRehabilitation (2007)Developed in affiliation with the BritishCardiac Society and cited in theImplementation Advice accompanyingthe NICE clinical guideline 48, thisdocument defines minimum standardsand core components for cardiacrehabilitation services and will helpcommissioners, providers, patients andthe public to understand what a goodservice looks like and to raise standardsacross the country. The minimum

standards relate to the infrastructure tosupport cardiac rehabilitation and thecontents of a programme are definedby the recommended core components. www.bcs.com/documents/affiliates/bacr/BACR%20Standards%202007.pdf

Two supplements to the Standards andCore Components on Staffing ofCardiac Rehabilitation programmes andAutomated External Defibrillators(AEDs) and Exercise were published in2009. It is anticipated that theStandards will be updated in 2010.www.bcs.com/pages/page_box_contents.asp?navcatID=49&PageID=625

The Cochrane CollaborationThe Cochrane Collaboration is aninternational, independent, not-for-profit organisation which provides up-to-date, accurate information about theeffects of health care. Contributorswork together to produce systematicassessments of healthcareinterventions, known as CochraneReviews (www.cochrane.org/cochrane-reviews), which are published onlinein The Cochrane Library(www.thecochranelibrary.com).Cochrane Reviews answer clinical

questions about the effectiveness oftreatments and are intended to helpproviders, practitioners and patientsmake informed decisions about healthcare.

The Cochrane Library houses a numberof relevant reviews investigating theeffects of cardiac rehabilitation.www.cochrane.org/information-practitioners

Department of Health (2000)Coronary heart disease: nationalservice framework for coronaryheart disease - modern standardsand service modelsThe National Service Framework forCoronary Heart Disease (NSF CHD),published in March 2000, set out astrategy to modernise CHD servicesover ten years. It details 12 standardsfor improved prevention, diagnosis,treatment and rehabilitation and goalsto secure fair access to high qualityservices. The chapter on cardiacrehabilitation, one of seven clinicalchapters, sets out how the NHS andothers can best help people who havehad a heart attack, revascularisation orother cardiac event maximise their

http://www.library.nhs.uk/CARDIOVASCULAR/ViewResource.aspx?resID=346140

http://www.acpicr.com

http://www.bcs.com/documents/affiliates/bacr/BACR%20Standards%202007.pdf

http://www.bcs.com/pages/page_box_contents.asp?navcatID=49&PageID=625

http://cochrane.org/cochrane-reviews

http://www.cochrane.org/information-practitioners



chances of leading a full life andresuming their place in their community(Standard 12). At the time ofpublication it was anticipated that fullimplementation would take 10 years ormore.

In 2010, the Department of Healthindicated that the focus is now onthose areas that have developed moreslowly than others, including cardiacrehabilitation.www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Coronaryheartdisease/Nationalserviceframework/index.htm

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275

Department of Health VascularProgramme Team (2008) Treatmentof Heart Attack National Guidance,Final Report of the National InfarctAngioplasty Project (NIAP)The National Infarct Angioplasty Project(NIAP) is a feasibility study looking athow far primary angioplasty can berolled out as the main treatment forheart attack in place of clot-bustingdrugs. This is the final report concludingthat it is feasible to roll out primary

angioplasty for the majority of Englandwithin acceptable treatment times. TheReport includes guidance whichupdates previous guidance ontreatment of heart attack in theNational Service Framework forCoronary Heart Disease. This guidanceis intended to encourage best practiceand to inform commissioners, cardiacnetworks and service providers in theirdiscussions on the configuration ofacute services, including the provisionof discharge planning, aftercare servicesand access to cardiac rehabilitationprogrammeswww.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_089454.pdf

Department of Health: The NHSOperating Framework for Englandfor 2010/11The operating framework for the NHSfor 2010/11 sets out the priorities forthe NHS for the year ahead to assistwith planning. Although the nationalfocus for the past three years hasremained broadly the same, thepriorities in 2010 touch on other issuesthat PCTs and their providers will wantto be mindful of and include specificreference to cardiac rehabilitation:

“The Department recognises that theremay be unacceptable variation in theavailability of cardiac rehabilitation. Weshall look to develop a set of indicatorsto improve general access to cardiacrehabilitation because it can lead toimproved outcomes and reducedemands for acute hospital beds.”www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@perf/documents/digitalasset/dh_110159.pdf

Department of Health: Revision tothe NHS Operating Framework forEngland for 2010/11The revised Operating Framework,published in June 2010, makes specificreference to the forthcomingCommissioning Pack on CR (p.11). “Tosupport the development of pathwaytariffs, a number of ‘commissioningpacks’ are in production, starting withcardiac rehabilitation, which is to bepublished shortly.”www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_110107

Department of Health (2010) TheNHS Quality, Innovation,Productivity and PreventionChallenge: an introduction forcliniciansThis booklet has been published tosupport clinical teams and NHSorganisations to meet the quality,innovation, productivity and prevention(QIPP) challenge and provides ways inwhich NHS clinicians can all getinvolved in shaping the response locally.

The National Cardiac RehabilitationAudit Project (NACR)The National Audit of CardiacRehabilitation (NACR) is a collaborationbetween the British Heart Foundation,the British Association of CardiacRehabilitation, the Coronary HeartDisease networks, the Department ofHealth and the Healthcare Commission,designed to improve cardiacrehabilitation services at the local andnational levels. The Audit is part of theCentral Cardiac Audit Dataset (CCAD)programme run by the NHSInformation Centre. The NICEImplementation Advice published tosupport Clinical Guideline 48recommends participation in and use of

http://www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Coronaryheartdisease/Nationalserviceframework/index.htm

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_089454.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@perf/documents/digitalasset/dh_110159.pdf

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_110107



the NACR to collect baseline data andmonitor implementation of the NICEguideline. The Audit produces anAnnual Statistical Report on cardiacrehabilitation in the UK and is the onlynational source of information onuptake, activity and outcomes ofcardiac rehabilitation.www.cardiacrehabilitation.org.uk/dataset.htm

National Institute for Health andClinical Excellence (NICE) ClinicalGuideline 48 (2007) Secondaryprevention in primary andsecondary care for patientsfollowing a myocardial infarctionThis national guideline for the NHSoffers best practice advice andrecommendations on secondaryprevention for patients in primary andsecondary care after a myocardialinfarction (MI). It includes specificguidance on cardiac rehabilitation afteran acute MI (see Section 1.2). As withall NICE guidance, this nationallyagreed guideline should be taken intoaccount by commissioners whenplanning and delivering care.http://guidance.nice.org.uk/CG48/NICEGuidance/pdf/English

NICE has also publishedImplementation Advice for this ClinicalGuideline:www.nice.org.uk/nicemedia/pdf/word/IAFINAL.doc

National Institute for Health andClinical Excellence (NICE) ClinicalGuideline 5 (2003) Chronic heartfailure: Management of chronicheart failure in adults in primaryand secondary careThe NICE chronic heart failure guidelinemakes recommendations about:• the care provided by GPs and hospitalhealthcare professionals who have direct contact with patients with heart failure

• all the key areas of managing heart failure including diagnosis, drug and non-drug treatments and the management of depression and anxiety.

Section 1.2 on treating Heart Failurerecommends that, “Patients with heartfailure should be encouraged to adoptregular aerobic and/or resistive exercise.This may be more effective when partof an exercise programme or aprogramme of rehabilitation”.http://guidance.nice.org.uk/CG5/NICEGuidance/pdf/English

Scottish Intercollegiate GuidelinesNetwork (SIGN) Guideline No. 57(2002) Cardiac RehabilitationThe Scottish Intercollegiate GuidelinesNetwork (SIGN) develops evidencebased clinical practice guidelines for theNational Health Service (NHS) inScotland. Guideline No. 57, supportedand endorsed by the BACR, providesevidence-based recommendations forbest practice in cardiac rehabilitation.

It is primarily concerned withrehabilitation following myocardialinfarction (MI) or coronaryrevascularisation, but also addresses therehabilitation needs of patients withangina or heart failure.www.sign.ac.uk/pdf/sign57.pdf

http://www.cardiacrehabilitation.org.uk/dataset.htm

http://guidance.nice.org.uk/CG48/NICEGuidance/pdf/English

http://www.nice.org.uk/nicemedia/pdf/word/IAFINAL.doc

http://guidance.nice.org.uk/CG5/NICEGuidance/pdf/English

http://www.sign.ac.uk/pdf/sign57.pdf

Arguably, the greatest challenge for theNHS over the next decade and beyondis to continue to deliver a commitmentto a service with quality as itsorganising principle through a period ofsignificant financial challenge byconcentrating on improvingproductivity and eliminating waste.

In order to achieve the vision, the NHSmust continue to deliver a commitmentto a service with quality as itsorganising principle through a period ofsignificant financial challenge byconcentrating on improvingproductivity and eliminating waste.

Since the launch of the CHD in NSF in2000, a considerable amount ofmomentum has been applied to drivingup standards of care in cardiacrehabilitation, on improving quality andtackling inequalities, often with limitedfunding.



The NHS Quality, Innovation, Productivity and Prevention (QIPP) challenge

The challenge for cardiac rehabilitationin moving forwards is no different. Butit is now more important than ever thateach pound spent on cardiacrehabilitation is focussed on providingclinically effective and high quality care,as well as improving patient safety andexperience.

The Priority Projects have highlightedthat sometimes simple changes canresult in improvements in efficiency,safety and patient care which could, ifimplemented across the NHS, result insignificant savings. In short, theprogramme has shown that innovationcan be a major driver of quality andproductivity improvements.

In October last year, the interim reportfor the National Priority Projects8

identified the following quality,innovation, productivity and prevention(QIPP) benefits after just 12 months ofthe programme:

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 Ischaemic Heart Disease (IHD)

• Cardiac rehabilitation outcome measures identified

• Clear management plans• Effective use of staff and programmes– no shutdown of services

• Implantable Cardioverter Defibrillator (ICD) rehabilitation (rolled out)

• Rehabilitation led follow up.

Experience• Increased patient choice• Care provided closer to home• Relevant patient information• Discovery Interviews, patient forums and patient questionnaires to inform development of services which meet patient needs.

INNOVATION

• Rehabilitation led follow up• Looking at ways to include NHS Health Check

• Drug therapy reviews• Task group acting to coordinate all quality initiatives.

PRODUCTIVITY

• Increased number of patients accessing rehabilitation services

• Reduced hand offs – integrated team with fewer referral steps

• Using and scheduling staff more effectively

• Rehabilitation led follow up – reducesthe need for outpatient attendance

• Ensuring availability of multidisciplinary team (MDT) staff to increase flow.

8NHS Improvement (2009) Cardiac Rehabilitation National Priority Projects: lessons and learning one year on



The example on the right illustrateshow one of the priority project sites hassought to align new community cardiacrehabilitation services with the QIPPagenda.

Quality: the new model will improve patient safety as the single point of referral and patient tracking will ensure thatall eligible patients are recruited to the programme. Standardised protocol and procedures will operate across the areaand can be assessed against the evidence base for cardiac rehabilitation. The commissioned service will be able todemonstrate its effectiveness by close monitoring of the health outcomes of patients attending cardiac rehabilitation aswell as the referral and waiting times experienced by patients. Commissioners will also be ensuring value for money byagreeing activity based contracts with the provider which will reward high uptake levels. Patients will experience abetter service as they will be provided with increased patient choice, care closer to home and a more flexible servicethat can provide a service for people with limited mobility and co-morbidities.

Innovation: the service model uses an ‘opt out’ system rather than the current model which is ‘opt in’. By referringpatients directly into an assessment clinic where they can be fully informed of the choices available to them, patientswill be able to make informed decisions about whether they want to participate in the programme. This innovativemodel aims to be more inclusive and attract a higher degree of participation from groups traditionally less likely toattend (women, people with co morbidities, black and ethnic minorities).

Productivity: the commissioning of a cardiac rehabilitation service will increase productivity in the following ways: • Attainment of offer and uptake rates as defined in the NSF for CHD • Increase referral to cardiac rehabilitation and therefore referral on to other lifestyle support services such as smoking cessation and weight management

• Ensure the PCT is achieving value for money by moving towards an activity based contract and standardising costs• Closer working between cardiac rehabilitation service and primary care ensuring that patients with CHD and heart failure benefit from sustained management and follow up after they complete rehabilitation.

Prevention: cardiac rehabilitation is a secondary prevention service; therefore one of its primary goals is to preventpatients from suffering another cardiac event in the future. There is evidence to show that cardiac rehabilitation helpspeople fight back against chronic illness by developing healthy lifestyle behaviours, it can prevent anxiety anddepression and also help people deal with social issues such as re-entering employment and understanding andobtaining benefits.

As indicated in its introduction toclinicians9 on QIPP, the Department ofHealth has established that:

innovation (especially thewidespread adoption of bestpractice) and prevention (inthe medium term throughsecondary prevention, and,over the longer term, throughprimary prevention) will be keyenablers for achieving qualityand productivity gains.”

It is clear from the interim benefits andmany of the major achievements andkey learning points outlined in thisdocument that cardiac rehabilitationwill continue to have a central role inhelping the NHS to achieve its vision ofbecoming more productive, people-centred and preventative.

“

9Department of Health (2010) The NHS Quality, Innovation, Productivity and Prevention Challenge: an introduction for clinicians

Taking StockPublished in March 2000, the CHD NSFset out a strategy to modernise CHDservices. It details standards forimproved prevention, diagnosis,treatment and rehabilitation andincludes goals for securing fair accessto high quality services.

Over the course of the last ten years,excellent progress has been made andthe Public Service Agreement target toreduce the death rate from CHD, strokeand related diseases in people under 75by at least 40 percent was met fiveyears early.

However, although the death rate fromCHD is falling, advances in thetreatment and management of heartattacks and improved survival in peoplewith impaired cardiac function,combined with an aging population,mean that the burden of disease isgrowing and becoming moreconcentrated in older age groups.



Next steps in transforming cardiac rehabilitation

At the time of publication, theDepartment of Health indicated that‘For the whole NHS and other bodies toimplement the NSF in its entirety couldtake 10 years or more’. 2010 does notmark the end of the CHD NSF’simplementation. Much of what is inthe NSF is as relevant now as it was tenyears ago, and much of it will still berelevant in the future. But, ten years onfrom publication, the Department istaking stock – looking at why suchexcellent progress has been made insome areas while others, like cardiacrehabilitation, have remained‘unfinished business’. The resultingreview of the impact of the NSF aims todistill key success factors as well asexploring barriers to implementation.

Commissioning for ImprovementMany of the problems associated withundesirable variations in service deliveryand access to high quality cardiacrehabilitation are underpinned by thefact that in spite of the impetusgenerated by the NSF, NICE, BACR andthe National Audit, among other levers,funding and commissioningarrangements for CR remain largely adhoc with CR seen as an ‘optional extra’rather than a vital part of treatment.

Experience from the field suggests thatthe establishment of robustcommissioning arrangements for CR islikely to result in improved access,uptake, coverage and quality. In view ofthis, and in parallel with theDepartment’s comprehensive review ofthe NSF, NHS Improvement has beenworking alongside the StrategicCommissioning Development Unit(SCDU) at the Department of Healthand other interested parties to developa Commissioning Pack for CardiacRehabilitation.

The Pack is designed to:

• Provide materials to help commissioners stimulate interest and contract effectively with both incumbent and new providers;

• Include service specifications and procurement templates which will focus on ensuring the delivery of high-quality responsive care, while allowing providers flexibility to develop innovative delivery models;

• Include advice to commissioners on procurement, contractual matters and issues such as pricing and risk management;

• Be capable of being adapted to encourage innovative delivery modelsand reflect local circumstances;

• Minimise unwarranted variations in the delivery of care: early diagnosis and managing conditions better prevents expensive exacerbations, with benefits throughout the health system.



In essence, the Pack will enable theeffective commissioning of CR services;ensuring the shape of CR servicesreflects best clinical evidence and use ofCR resources are optimal. This will raiseboth quality and productivity of CRservices and will help to meet thechallenge of providing timely access togood quality CR.

National Heart Projects 2010/11To support the development,implementation and roll out of theCommissioning Pack for CR, NHSImprovement is planning to recruit anumber of project sites to help test theutility of the pack in real life settings.

Building on the firmfoundations set by theNational Priority Projects in2009/10, the primary aimof this excitingprogramme of projectwork will be to increaseaccess to and uptake ofcardiac rehabilitation andto improve the quality ofCR services through

effective implementation of the newCardiac Rehabilitation CommissioningPack.

It is envisaged that the pack will proveto be a practical guide to help NHSorganisations commission CR servicesmore efficiently, encourage greaterinnovation and productivity in the wayin which services are provided andultimately improve services and qualityoutcomes for NHS patients and theircarers and families. In doing so,implementation will supportorganisations to deliver the Quality,Innovation, Productivity and Prevention(QIPP) agenda.

The projects are due to commence induring 2010 following the publicationof the CR Commissioning Pack and willrun until March 2011 initially, in linewith national priorities.

In keeping with the ethos of NHSImprovement, key learning andachievements will be shared nationallythrough a variety of different media,including workshops, conferences,publications and the website atwww.improvement.nhs.uk/heart/cardiacrehabilitation.

If you would like to know more about the Cardiac Rehabilitation Commissioning Pack or the NationalHeart Projects for 2010/11, please contact the workstream Director orNational Improvement Leads below:

Julie HarriesDirector, NHS [email protected]: 07810 836305

Linda BinderNational Improvement Lead, NHS [email protected]: 07747 603978

Mel VarvelNational Improvement Lead, NHS [email protected]: 07917 504894

Sarah Armstrong-KleinNational Improvement Lead, NHS [email protected]: 07917 505265

Lesley ManningProgramme Support Team, NHS [email protected]: 0116 222 5244



NHS Improvement System

What is it?The NHS Improvement System is acomprehensive, online tool tosupport sharing of quality serviceimprovement resources in NHSservices. Giving you direct access touseful information and stories fromaround the country, it will assist youin your own service improvementwork.

Why use it?The NHS Improvement Systemactively helps organisations toeffectively achieve their objectives inline with national and local policy andstrategy. It enables users to be morestrategic and align long-term goalsthat can help to deliver high quality,patient focussed health outcomes.

Which specialties are included? The system can be used to supportsustainable service improvement in any specialty.

What does it contain? • Service improvement tools and resources

• Practical guidance • Case studies • Useful contacts • Signposting and links.

Where can I see a demonstration of the system?Demonstrations of some of the keymodules are available on theimprovement system home page at:www.improvement.nhs.uk/improvementsystem

Who can use the system?The system is free of charge and canbe used by all staff working for NHSorganisations in England.

How can I register to use thesystem?Access to the system is controlled by user ID and password.

To request an ID [email protected]

http://www.improvement.nhs.uk/improvementsystem

Cardiac Rehabilitation National Project Team

NHS Improvement

Julie HarriesDirector - NHS [email protected]

Linda BinderNational Improvement LeadNHS [email protected]

Mel VarvelNational Improvement Lead NHS [email protected]

Sarah Armstrong-KleinNational Improvement LeadNHS [email protected]

Lesley ManningProgramme Support [email protected]

National Clinical Leads

Professor Patrick DohertyNational Clinical [email protected]

Dr Jane FlintNational Clinical [email protected]

NHSNHS Improvement

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS Improvement

With over ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensure valuefor money to improve the efficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart, lung and stroke services.

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Delivering tomorrow’simprovement agendafor the NHS

HEART LUNGCANCER DIAGNOSTICS STROKE

transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the...

Health & Medicine