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The 7 th 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

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the 7 th york cardiac care conference why does cardiac rehabilitation struggle for funding

The 7thYork Cardiac Care ConferenceWhy 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
Historical perspective

30 years on……

slide3

100

225

35

225

140

slide4

20%

7%

45%

28%

challenges for cardiac rehabilitation
Challenges for Cardiac Rehabilitation
  • Increasingparticipation (daytime sessions preferred by elderly, women, housewives, husbands, non-car owners)
  • Increasingcompliance (employed often require evenings, shiftworkers need day/eve options)
  • Increasingcapacity (additional income, health club, ex-patients and partners, NHS staff and partners, exercise referral scheme for high risk primary preventive, other medical conditions)
  • Increasingchoice (to suit lifestyle eg grandparents need to avoid the school run)
important part of success
Important part of success

Patients, Carers and Volunteers

patient and carer involvement
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
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
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
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
Percentages of patients reported referred to ‘rehabilitation’ in MINAP, J. Birkhead June 2003
cardiac rehabilitation and cardiac networks
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

Straw poll survey of Networks
questions to networks ejf linda binder 2007
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
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 criticalleveloffunding for rehabilitation community development
1 2 2 the cardiac rehabilitation team will include a cardiologist
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 1980 2000
Explaining Mortality Reduction 1980-2000

48% of CVD mortality reduction since 1980 has come from reductions in smoking.

32% of reduction comes from secondary prevention and other primary prevention.

Informed assessment from analysis of english language literature in England, US,and Europe

Circa 60% from risk factor modification

Circa 40% from treatment

Smoking reduced 48%

Secondary prevention

Blood pressure

lowered 9.5%

11%

Thrombolysis & other AMI

Fat

reduced 9.5%

8%

Surgery or drugs for angina

Reduced

deprivation 3%

5%

Treatment for hypertension

Increased risk of

obesity/physical

inactivity -12.%

3%

Other

13%

Primary sources Belgin et al [2004], Capewell et al [1999] , McPherson [2001]

pci compared with exercise training in patients with stable cad
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
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
Successful Health Alliance

Recognised by Department of Health 1993

Beacon Award 2000

slide24

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.

recommendations
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
change as an equation f d v s m r
Change as an equationF ( 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
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
acknowledgements
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