The 7th York Cardiac Care Conference Why does cardiac ...

The 7th York Cardiac Care Conference Why does cardiac ...

The 7th York Cardiac Care Conference Why does cardiac rehabilitation struggle for funding? Dr Jane Flint BSc MD FRCP Medical Director Action Heart Dudley Clinical Director Black Country Cardiac Network President BACR 1997-9, Member NSF External Reference Group British Cardiovascular Society Council and British Heart Foundation Trustee

Historical perspective 30 years on Action Heart Income (000s) Cardiac Rehabilitation 100 225 225 35

Donations and Fundraising Other Clinical Services 140 Health Club Income Source of Action Heart Income (%) Cardiac Rehabilitation

20% 7% 45% 28% Donations and Fundraising Other Clinical Services Health Club Income

Challenges for Cardiac Rehabilitation Increasing participation (daytime sessions preferred by elderly, women, housewives, husbands, non-car owners) Increasing compliance (employed often require evenings, shiftworkers need day/eve options) Increasing capacity (additional income, health club, expatients and partners, NHS staff and partners, exercise referral scheme for high risk primary preventive, other medical conditions) Increasing choice (to suit lifestyle eg grandparents need to avoid the school run)

Important part of success Patients, Carers and Volunteers Patient and Carer Involvement Support for fellow patients and carers (and within Network Patient & Carer Partnership) Volunteer staff ( equiv. value 40,000 p.a.) Feedback and consultation on services and pathways (QPDT, LIT & Network too) NICE group

Finance Capital bids initially New Opportunities Fund/BHF Partnership to deliver grant programmes for community based cardiac rehabilitation and heart failure networks (14 million) - focussed projects with targets - complement existing provision - further access to sustainable development - partnership/continued funding Finance 2

Patients Choice programme suspect variable level of investment Recurring 100million: 70% CABG/PCI NB to fund pathway including cardiac rehabilitation (also cath lab, PCAs etc) All PCTs have extra 9% funding Major capital developments should include costs of entire patient pathway including primary and secondary care ( CR and SP) Heart Team, May 2003 So why the struggle?

Limited ring-fenced funding/access Lack of appropriate outcome target, despite service standards Lack of audit information until NACR Lack of appointed leadership at all levels national, network, LIT, QPDT Lack of commitment/ power to change Compelling, competing priorities ?PbR (not alone) Change to PCT responsibility, but also LITs and Networks which should be planning/ commissioning services

Percentages of patients reported referred to rehabilitation in MINAP, J. Birkhead June 2003 Cardiologist Other Physician Yes 76 No

12 Unknown 12 Non STEMI 69 18

13 STEMI 70 14 16 Non STEMI

64 20 16 STEMI Cardiac Rehabilitation and Cardiac Networks Ideal service for Network planning

Work plans 2006/7: only 18 out of 32 included CR 2007/8: 23 out of 32 have CR in draft plans, but competing priorities for funding with 18 week target, and Network reorganisation has carried forward plans for CR reviews Straw poll survey of Networks CR reviews informing work plans in majority of 18:32

Cross-Network protocols, strategy & business case for leverage Work slowed with PCT/ SHA/Network project manager change Anxiety about PbR tariff being used to stall progress

Questions to Networks EJF/Linda Binder 2007 14 of 23 with CR plans engaged Majority DO NOT have a Cardiologist championing CR LITs reconfiguring in 10 with variable CR representation at any time (some no LIT at all or disbanded) Network: commissioner liaison in 5 of 14 Networks (7 of 32 report linking with PBC in work plans) Service standards variable, majority try to follow BACR, 2 have adopted West Midlands standards 5 of 14 had definite access to original Patient Choice

monies (most aware of possibility, just 2 not) 12 of 14 received some NOF funding, all with a CR specific component to bid BHF/NOF Rehabilitation 2004 Areas in 22:32 Cardiac Networks were successful in their rehabilitation bids likely to underpin the work plans now volunteered. Concept of critical level of funding for rehabilitation community development

1.2.2 The cardiac rehabilitation team will include a cardiologist British Cardiovascular (previously Cardiac) Society recommendation - District Working Party 1994; Interface Report 1997; Fifth Joint Report 2002 Explaining Mortality Reduction 19802000 48% of CVD mortality reduction since 1980 has come from reductions in smoking. 32% of reduction comes from secondary prevention and other primary prevention.

Smoking reduced 48% Blood pressure lowered Fat reduced Reduced deprivation Increased risk of obesity/physical inactivity

9.5% 9.5% 3% -12.% Circa 60% from risk factor modification Circa 40% from

treatment Informed assessment from analysis of english language literature in England, US,and Europe Secondary 11% prevention Thrombolysis & 8% other AMI Surgery or drugs

5% for angina Treatment for 3% hypertension 13% Other Primary sources Belgin et al [2004], Capewell et al [1999] , McPherson PCI without comprehensive risk factor modification is a sub-optimal therapeutic strategy PCI compared with Exercise

Training in Patients with stable CAD Compared with PCI, 12-month programme of regular physical exercise in selected patients with stable CAD resulted in superior event-free survival and exercise capacity at lower costs, notably owing to reduced rehospitalizations and repeat revascularisations. Hambrecht,R et al. Circulation 2004;109:1371-1378 NACR 2005-6 cost of CR 413 Modest compared with CCU stay, PCI or CABG

Cost-effective Underpins expert patient development/further empowerment of heart patients BUT Little revenue for private sector No marketplace advantage for service true/false? Major lifestyle improvement will SAVE resource Successful Health Alliance Recognised by Department of Health 1993

Beacon Award 2000 Walking route location Thanks to 4th, 5th and 3rd year Medical students On pilot; David Cole Of Directorate Of the Urban Environment Graphic Design studio; Russ Tipson, Director of

Action Heart; Barbara White, Dudley Clinical Education Centre Manager. Neighbourhood Walk Information Recommendations Cardiac rehabilitation should be firmly established in partnerships with the local community to achieve targets PPI provides a major empowering contribution BHF/ NOF funding has made the greatest contribution

since the NSF for CHD extend innovation Cardiac Networks should ALL have CR work plans encouraged by HIP, and led by a local Cardiologist with commitment to see CR represented in all relevant fora Patient Choice revascularisation funding stream should include accountability for the CR pathway in re-alignment of resources with changing work patterns Champion Patient Change as an equation F(D+V+S+M)>R

D = Dissatisfaction with the current situation V = Vision of the future in some form S = An idea of what the next steps might be M = Mindset that it is right and possible to do R = Reluctance or resistance to change Cardiac Rehabilitation D: many patients still cannot access CR V: NSF, SIGN, AACVPR, JBS2, ACPICR, BACR IV, ACSM, NICE

S: protocol/ICP driven management and audit NACR M: Fifth report; HCC NSF review; BCS Peer Review R = neglect reducing, BUT workforce constraints and poor share of resource Be the change you want to see Acknowledgements Russell Tipson, Team and Patients, Action Heart, Dudley

Black Country Cardiac Network Rehabilitation sub-group to Clinical Governance Group Linda Binder, NHS Heart Improvement Programme David Geldard, President Heart Care Partnership UK and Trustees

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