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

NHS
NHS Improvement
CANCER

DIAGNOSTICS

NHS Improvement Heart
Transforming cardiac rehabilitation: celebrating achievements
HEART
and sharing the learning from the national projects

LUNG

STROKE

Contents

Foreword 3 Achievements and key learning points by site 28
Professor Patrick Doherty, National Clinical Lead
for Cardiac Rehabilitation, NHS Improvement Contact information for site project managers 38

Reflections from the Clinical Leads 4 Supporting information 39
Professor Patrick Doherty, National Clinical Lead, NHS
Improvement and Dr Jane Flint, National Clinical Advisor, The NHS Quality, Innovation, Productivity and 42
NHS Improvement Prevention (QIPP) challenge

Introduction 6 Next steps in transforming cardiac rehabilitation 44

Chapters NHS Improvement System 46
1. UNDERSTAND YOUR SERVICE 8
2. ENGAGE WITH YOUR STAKEHOLDERS
Cardiac Rehabilitation National Project Team 47
10
3. INVOLVE PATIENTS AND CARERS 12
4. ENLIST CLINICAL LEADERSHIP 14
5. COLLECT, ANALYSE AND MAKE USE OF ROBUST DATA 16
6. SPECIFY YOUR SERVICE REQUIREMENTS 18
7. COMMISSION EFFECTIVELY 20
8. USE RESOURCES WISELY 22
9. COLLABORATE AND NETWORK 24
10. SEE THE BIGGER PICTURE 26

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

Foreword
Cardiac rehabilitation (CR) is a vital part of often sub-optimal. These problems are rehabilitation services across the country. I’m delighted that in 2010/11 NHS
caring for patients with heart disease. It is an underpinned by the fact that funding and Launched in September 2008, the National Improvement is planning to launch a new
evidence-based and cost effective commissioning arrangements for CR are Priority Project identified twelve sites across round of projects to test the utility of the
intervention that reduces future mortality largely ad hoc in many areas, with CR seen the country attempting to increase access, Commissioning Packs in raising both the
and morbidity and improves quality of life. as an ‘optional extra’ rather than a vital part equity and uptake to CR through quality and efficiency of CR services.
of treatment. implementation of the National Institute for
Over the past decade, the Coronary Heart Health and Clinical Excellence (NICE) The momentum and enthusiasm for CR has
Disease National Service Framework (CHD All in all, CR remains part of the ‘unfinished recommendations for cardiac rehabilitation been sustained over time by the CHD NSF,
NSF) and related initiatives have led to a business’ of the NSF and there is a long way and the associated commissioning guidance. NICE guidance, BACR Standards and Core
significant reduction in the rate of premature to go to meet the challenge of providing This final report celebrates some of their key Components, National Audit of CR, NHS
death from CHD with some clear timely access to good quality cardiac achievements, as well as documenting many Improvement Priority Projects and other key
improvements in CHD services across the rehabilitation. of the invaluable learning points that, once developments in the field that have
pathway of care. But there are areas, shared, will help others to drive up standards collectively created an opportunity for large
including cardiac rehabilitation, that were 2010 does not mark the end of the CHD of care without reinventing the wheel. scale improvement in CR services. The
not well positioned to benefit from the initial NSF’s implementation. Much of what is in achievements realised so far are testament to
front line investment and have developed the NSF is as relevant now as it was 10 years Evidence accrued from NHS Improvement the hard work and commitment of all those
less quickly than others. ago, and its approach continues to stand the and the CR National Priority Projects plus who work in the field. The challenge in
test of time. But there is a need to review other clinical areas implementing innovation going forward will be to maintain the
Despite the collaborative and sustained and examine why we have been able to suggests that the establishment of robust impetus and sustain improvements so that
efforts of a wide range of partners, make such excellent progress in some areas commissioning arrangements for CR is likely we can build on what we have learnt in the
awareness and uptake of CR remains low. but not in others - and we need to do this in to result in improved access, uptake, face of fresh challenges and continue to
The National Audit of Cardiac Rehabilitation the context of the greatest financial coverage and quality. Hidden inside the 38% drive up standards and strive for excellence
(NACR 2009) identified that on average only challenge that the NHS has ever faced. Over average uptake are islands of excellence that in cardiac rehabilitation.
38% of heart attack, angioplasty and bypass the next few years, at the same time as have made huge inroads to offering high
patients received cardiac rehabilitation in continuing to deliver high quality services quality CR to the majority of patients. With My thanks to all those who have contributed
2007/08 and there are marked geographical and ensuring areas like cardiac rehabilitation this in mind, NHS Improvement has been to delivering these marvelous improvements.
variations in access to CR services across the that have lagged behind are brought up to working alongside the Strategic
country. Access for people with different the same high standard, the NHS will need Commissioning Development Unit (SCDU) at
cardiac conditions (e.g. people with heart to focus firmly on delivering care much more the Department of Health and other key
failure) and for various different populations efficiently. partners to develop a Commissioning Pack
(e.g. women, black and minority ethnic for Cardiac Rehabilitation. In essence, the Professor Patrick Doherty
groups) is also variable. Many existing Over the life of the NSF, the Department of pack will facilitate more effective National Clinical Lead for Cardiac
services do not meet the minimum standards Health has been working with NHS commissioning of cardiac rehabilitation; Rehabilitation to NHS Improvement
and core components set by the British Improvement and the cardiac networks to ensuring the shape of CR services reflects
Association of Cardiac Rehabilitation (BACR) spread good practice and to help increase best clinical evidence and use of CR
so that the quality of care patients receive is the quantity and quality of cardiac resources are optimal.

www.improvement.nhs.uk/heart 3


Reflections from the Clinical Leads
The NHS Improvement National Priority commissioning of new services. This has The projects have been a real success in
Project for Cardiac Rehabilitation (NPP for culminated in substantial shared learning delivering a measured improvement at a
CR) came out of a long standing and experience that has led to major challenging time for NHS services and
commitment in the NSF for CHD to deliver innovations in redesigning clinical everyone who participated should be
effective rehabilitation as part of patient pathways and specification development congratulated!
care following a cardiac event or plus tangible decreases in waiting times
procedure. In order to implement this and improved uptake to services. There
commitment there was a clear need to have been clear lessons learnt about
offer national support to local providers, implementing and measuring quality and Professor Patrick Doherty
commissioners and cardiac networks to productivity initiatives many of which have National Clinical Lead for Cardiac
develop, implement and evaluate led to new and innovative service models Rehabilitation to NHS Improvement
innovative and productive approaches to that will withstand future service
addressing national and regional issues of pressures.
low uptake and inequalities of access to
services. The benefits to patients are also clear in
that projects have delivered greater
There have been twelve projects within uptake and equity in provision, enhanced
one year of inception of the NPP for CR patient risk assessment and safety and a
and all have achieved major positive more flexible approach to service delivery
changes to their services. The projects, underpinned by patient choice.
which were supported by a combination
of high quality clinical teams, perceptive
commissioners and strongly committed
patient representatives, have tackled
varying aspects of service delivery or

4 www.improvement.nhs.uk/heart


Our CHD NSF ‘unfinished business’ of The National Cardiac Conference in March The principle of conducting a thorough,
Cardiac Rehabilitation (CR) has benefited 2010 allowed us to celebrate the review individualised assessment of cardiac
from National Priority Projects tackling of the post Primary Percutaneous patents for their rehabilitation and
pathways, commissioning and Coronary Intervention (PPCI) pathway secondary prevention needs remains
inequalities, working towards their two following STEMI, there being major central and will be further captured with
year achievements herein summarised. improvement in the approach to use of the Commissioning Pack. Evidence
rehabilitation of these patients in leading for the value of CR for people with heart
Key learning points from the journey so Networks. The example of PPCI roll-out failure is gathering momentum and the
far provide essential lessons for Networks contained within this document potential for CR to contribute to a
and their cardiac rehabilitation exemplifies the need to commit to reduction in occupied bed days and
programmes: engagement of all improving referral and uptake to CR in all readmissions will help to demonstrate the
stakeholders, involvement of patients and cardiac pathways. QIPP value of investment in CR during
carers, enlisting clinical leadership, and these challenging times.
collaborating and networking so there can The encouragement and assessment of
be effective commissioning. CR development across the English
Cardiac Networks 2007-2010 has held
Understanding your service, specifying support of Networks and PCTs being able Jane Flint BSc MD FRCP
and embedding it within the health to redesign better and sustainable National Clinical Advisor for Cardiac
community, collecting, analysing and improvement in patient care at its heart. Rehabilitation to NHS Improvement
using data so resources may be used The Network surveys have revealed
wisely in the wider picture, are essential in Network Cardiologist Champions for CR
today’s constrained financial environment. as well as Programme Lead Cardiologists,
many appreciating a ‘Leadership
Development’ Day in November 2009.



Introduction
Over the past decade, NHS The National Priority Project for chairperson and National Clinical Lead, The Project was also keen to ensure
Improvement and its Collaborative Cardiac Rehabilitation and Dr Jane Flint, consultant that the following core issues were
predecessors have been working with cardiologist and National Clinical addressed:
NHS organisations and clinical networks Launched in September 2008, the Advisor, the National Project invited
to help transform services and deliver National Priority Project for Cardiac applications which focused on: • Reducing inequalities
sustainable improvements across the Rehabilitation (CR) selected nine • Increasing access to and information
entire pathway of care in a number of projects, comprising 12 NHS sites from • Identification and active engagement about CR services
clinical specialties- most notably cancer, across the country supported by the of eligible CR participants using a • Engaging patients/carers/families in
diagnostics, heart, stroke and now lung Cardiac and Stroke Networks, to drive systematic and structured approach planning services
services. Working closely with the forward improvements in cardiac • Development of mixed models of • Workforce and multi-disciplinary
Department of Health, NHS rehabilitation services. The overall aim provision tailored to meet the needs team approaches.
Improvement’s agenda is closely aligned of the National Project was to increase of individual patients
to national priorities and the access to, equity of provision for, and • Relevant rehabilitation for groups less Published twelve months after the
organisation plays a key role in uptake of CR services for patients likely to access the service such as commencement of the Project in
supporting the delivery and having heart attack and/ or women or ethnic minorities October 2009, the interim report on
implementation of national health revascularisation, in line with the • Development of exercise components the Cardiac Rehabilitation National
strategy. National Service Framework for CHD. In designed to meet the needs of older Priority Project: Lessons and Learning
doing so, the Project sought to pilot people or those with significant One Year On effectively summarised
Using tried and tested improvement implementation of the NICE co-morbidities the key learning from across all the
methodology in addition to novel and recommendations on cardiac • Joint agreement, planning and sites and aimed to share the initial
innovative approaches, NHS rehabilitation- as outlined in the NICE commissioning of services across outputs, outcomes and improvements
Improvement is working with a wide Clinical Guidelines on MI: Secondary hospital trust, GP practice, PCT and with a wider audience.
range of partners to test, model, prevention (NICE CG48, 2007)- utilising social/leisure services and at network
implement and spread the core the subsequent NICE Commissioning wide level
improvements and ‘winning principles’ Guide for CR services (2008). • Exploration of the feasibility of a
which have been shown to increase generic rehabilitation model
efficiency and drive up quality in Co-ordinated by Linda Binder, National encompassing other disease
patient care with the aim of making Improvement Lead for NHS modalities.
services better for patients and staff. Improvement, and supported by
Professor Patrick Doherty, BACR



Building on the ‘One Year On’ report These key learning points and the In addition to the themed chapters,
this second and final publication has achievements to which they relate have Transforming CR forges links between
been produced to celebrate success been distilled and grouped under a the improvements listed and the
and to highlight the major series of chapter headings, themes or requirement for all NHS services to
achievements across participating sites. common threads, which effectively focus on quality whilst at the same time
In line with the raison d’être of NHS represent the main ingredients in the achieving greater efficiency. It outlines
Improvement, Transforming CR: recipe for CR improvement ‘success’ next steps in transforming CR in terms
Celebrating Achievements and Sharing across the projects. of the forthcoming Cardiac
Learning from the National Priority Rehabilitation Commissioning Pack and
Projects aims to extract the key learning As part of NHS Improvement’s the next round of National Projects
points from the Project and share them commitment to reducing its carbon aimed at testing the utility of the Pack
with a wider, national audience. In footprint, Transforming CR has been in real life settings. Last, but by no
doing so, it endeavours to demonstrate designed to be read in electronic means least, Transforming CR points to
how cardiac rehabilitation services can format with a limited print run. In other useful sources of guidance,
drive up quality whilst improving keeping with this, and in order to share advice and information, including full
efficiency and achieve alignment with the learning in a more concise and contact details for each project site.
the overall strategic direction of the user-friendly manner, the learning
NHS. points and exemplar achievements have Generous thanks are extended to
been stripped down to their everyone who has contributed to
The development of Transforming CR fundamental core and presented in list Transforming Cardiac Rehabilitation by
has been a collaborative and iterative format. A summary of achievements sharing experiences, learning,
process. In May this year, project leads and key learning points can be found knowledge and guidance.
for each participating site were invited on page 28. Full transcripts of the
to attend a telephone ‘interview’ to interviews with individual project site
share just three headline achievements leads are available for download at
from their work - a difficult task in itself www.improvement.nhs.uk/heart/
given the number and quality of cardiacrehabilitation
improvements in CR services across the
National Project - and to detail any key
learning points associated with each
achievement.


1. UNDERSTAND YOUR SERVICE

“
Understanding your existing service is an
essential first step in redesigning processes
to make them better for patients and staff

Understand Your Service
Improvement is all about continually
In order to really get to grips with
improvement, to find out which Full transcripts of interviews with
”
working together to improve the improvements will make the biggest individual site managers are
experience and outcomes for patients difference and what benefits can be available to download at:
and users and looking for other ways achieved as a result, it’s really www.improvement.nhs.uk/heart/
to provide health care that important to understand where you cardiacrehabilitation
continuously improves the way it are now. Examining your current
meets the needs of those who depend service, exploring the environment
on it and the working lives of the staff and context that it exists in, and
who provide it1. gathering insight into patient and
staff experience is an essential first
step in getting to where you want to
go and identifying what you need to
do to get there.

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


Key learning points Exemplar achievement:
1. Know your own catchment area and analyse findings in light of this knowledge. Shropshire and Staffordshire Heart and Stroke Network
Black Country Cardiovascular Network Review of current service provision with options analysis and plans to move
towards a commissioned programme
2. Using the same benchmarking tool across the network ensures consistency of
approach across all services and helps to standardise services across the patch. Background and context
Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network A baseline audit in 2008 to highlight good practice and identify gaps in service indicated
that a redesign of the CR service in North Staffordshire was required to increase capacity
3. Be open to change and recognise that nothing is too precious to review and, if
and offer rehabilitation to all eligible patients in both hospital and community settings.
appropriate, change. Challenge yourself and others in the team. Encourage innovation
The audit demonstrated that for the more significant gaps in regional rehabilitation,
and don’t be afraid to break established ‘rules’ around service provision.
Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network
service funding plays a major role. Wherever possible cost neutral changes have been
implemented, yet without additional funding and engagement in primary care, any
4. Assumptions or anecdotal evidence need to be substantiated when looking at for the substantial service improvement is impossible.
reasons behind uptake/non-uptake of CR. Explore uptake in detail using geo-mapping
and audit data and be prepared to act on the findings. The cardiac rehabilitation team were keen to begin working on redesign and took the
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, opportunity to visit other centres in the country to look at new ways of working and
Dorset Cardiac and Stroke Network develop prospective plans as discussions with providers and commissioners began.

5. Conducting a comprehensive and rigorous audit to establish a baseline position, help After a number of discussions with commissioners and the appointment of a cardiac
understand if existing services are meeting the required standards, and provide real rehabilitation lead manager, an options analysis paper was compiled and the redesign
data to back up any anecdotal evidence is an essential first step for any new project work has started. It has been agreed that this work should be supported with a view to
seeking to improve the quality of patient care/ services (and win awards!). Make sure moving towards a fully commissioned service. With the development of the cardiac
audits are repeated to gauge progress and reset the baseline as improvements are rehabilitation Commissioning Pack the impetus has increased and this programme will
realised. be applying to become one of the new implementation sites.
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


2. ENGAGE WITH YOUR STAKEHOLDERS

“
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
Engage with Your Stakeholders
Stakeholders are those people and
groups who are affected by a project
or are important to its success. The
”
However, winning the hearts and
minds of those with a vested interest
in your project is not as simple as it
sounds. Successful engagement
The best approach is to analyse the
level of support required from each
individual or stakeholder group and
then direct attention towards
degree to which stakeholders are involves recognizing the different achieving it2.
engaged will affect the outcome of backgrounds and cultures of the
any improvement initiative. various stakeholders, understanding
Stakeholder engagement may take the ‘what’s in it for them’, and using Full transcripts of interviews with
many forms but is essentially a a variety of different tools and individual site managers are
continuous process combining techniques to hear and listen to their available to download at:
communication and involvement from experiences and needs. www.improvement.nhs.uk/heart/
the planning stages right through to cardiacrehabilitation
completion.

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


1. Engage service providers, individual staff groups and people at a senior level at a very Derbyshire County PCT
early stage. This will lead to earlier acceptance of the need for redesign. Effective stakeholder engagement
Peninsula Heart and Stroke Network
Background and context
2. Invest in real stakeholder engagement at every stage of the process and be prepared The CR working group made every effort to involve and consult with all key stakeholders
to adjust your ‘sales pitch’ and approach to appeal to different audiences in order to from the outset. The service specification went out to public consultation, as well as
encourage and sustain interest and involvement with different stakeholders. being presented to the local CHD strategic commissioning group, the Long Term
Derbyshire County PCT Conditions Programme Board and clinicians from primary and secondary care. Patient
representatives were involved in the development of the strategy and service
3. Be prepared to manage your market. Investing resources in informing and developing
specification, sat on the Procurement Project Board and were integral to the decision-
potential providers reaps rewards in terms of increasing understanding of the
making process. Their involvement lent credence to the process and far from being a
procurement process and the service specification.
tokenistic gesture; patients were fully engaged in the process and able to bring their
Derbyshire County PCT
varied and valuable experiences to bear on the outcome.
4. Establish good relationships with the local council/ exercise providers so that you can
flex the system and provide choice for patients. The recruitment of both an internal and external clinical lead was crucial to the
Derbyshire County PCT development of the pathway. The internal clinical lead provided important local
knowledge and clinical guidance and leadership. An external clinical lead was viewed as
5. Try to engineer a broad spread of stakeholder attendance at national meetings, being essential in terms of injecting the redesign process with objectivity, enabling
rotating staff/patient attendance as necessary/relevant in order to stimulate ideas, commissioners to make informed decisions and challenge current practice.
encourage innovation and maintain a wider perspective.
Shropshire and Staffordshire Heart and Stroke Network As the PCT intended the new CR pathway to bring care closer to home for patients, the
involvement and engagement of local general practitioners and their primary care
6. The provision of a focused workshop which catered specifically to the expressed colleagues was crucial. With this in mind, the PCT held a number of consultation events
needs of clinicians and commissioners was essential in securing positive and sustained for primary care colleagues on a locality basis, and targeted Practice Based
stakeholder engagement. Bringing clinicians and commissioners together and Commissioning clusters so that they could provide feedback to individual GPs.
involving them in the process of developing outcome measures- rather than
developing the measures and seeking comments retrospectively- enabled As an integral part of the procurement process, the PCT facilitated a ‘provider forum’ for
involvement to be viewed as a distinct opportunity. providers interested in tendering for the new service. The PCT used this opportunity to
South London Cardiac and Stroke Network
present and explore key aspects of the service specification in order to answer any
queries, challenge any misconceptions, and also to amend the service specification where
necessary. Moreover, utilising expertise brought in from the national procurement hub,
the PCT undertook to speak with all potential providers on an individual basis to
stimulate interest in the tender and provide as much information on the service
specification as possible.


3. INVOLVE PATIENTS AND CARERS

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

Involve Patients and Carers
Meaningful and effective patient and
communications between
commissioners and providers and
” creating genuine, continuous and
sustainable partnerships where all the
carer involvement is fundamentally the communities they serve will be people involved are acknowledged as
important in every aspect of improved. Overall, real patient and having a unique and important
improving health care. Aside from carer involvement and engagement contribution and are respected as
being a basic right, greater will lead to greater ownership and equals3.
involvement of patients, carers and understanding of local health services
the public in planning and delivering and why and how they need to
healthcare is likely to result in better change and develop. Full transcripts of interviews with
quality services that are more individual site managers are
responsive to the needs of patients, Far from ‘doing to’ or even ‘doing available to download at:
leading to better outcomes. Policy for’ patients, contemporary www.improvement.nhs.uk/heart/
and planning decisions are likely to approaches to involvement reach cardiacrehabilitation
be more patient-focused and beyond consultation and focus on

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


1. Discovery Interviews should be used for other service user groups such as heart failure Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network
or angina patients but also has a wider application across all service provision and Utilising Discovery Interviews to review and critically analyse the service from
clinical specialties. the patient perspective
Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network
Background and context
2. Regard patients and carers as equal partners in service redesign and development and Discovery Interviews, originally developed by the CHD Collaborative and utilised by
provide real opportunities for them to become involved in planning and cardiac networks and other areas nationally, are a well evaluated tool for learning about a
decision making. service from the patient perspective. Discovery Interviews use a semi-structured interview
Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network technique 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.
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 In the Dorset Cardiac Network a relevant Discovery Interview transcript is played at the
their own agenda. Provide patient and carer representatives with appropriate support beginning of meetings in order to allow staff to focus on the patient perspective and to
and training from a qualified and experienced Patient and Public Involvement (PPI) lead instigate discussion.
to ensure that they are able to contribute in a meaningful way and allow the patient
voice to be heard. One of the Discovery Interviews prompted all three CR teams across Dorset to hold a
Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network process mapping event focusing on patient letters, documentation and information
booklets with patients and staff. This resulted in revision of information to meet the
4. Ensure that appropriate steps are taken to safeguard patient confidentiality when
needs of the patients and helped to increase uptake of CR services – for example, one of
seeking to share patient data or feedback to improve care.
the revisions to information was to add the phrase ‘Your consultant has recommended
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust,
Dorset Cardiac and Stroke Network
that you attend cardiac rehabilitation….’- a compelling commendation for many patients.

5. Involve patients systematically in service improvement efforts, but understand and take The information review also facilitated the provision of standardised information and
advantage of any opportunities to gather feedback on patient experience. greater collaboration between centres in the network – particularly between
North West London Cardiac and Stroke Network Bournemouth and Poole, many of whose patients are eligible to attend the CR service at
either hospital. This was particularly relevant where Poole patients attend for angiogram
6. If you consider asking patients their opinion via a questionnaire or other method, there at Bournemouth and then may choose where to attend for rehabilitation. The same
has to be a robust mechanism for feedback of results and then follow up to information booklet from the catheterisation suite at Bournemouth is now given to all
demonstrate resulting actions. patients. This has helped prepare patients and carers for the next steps in the care
Shropshire and Staffordshire Heart and Stroke Network pathway and has helped to reduce anxiety.
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.

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


4. ENLIST CLINICAL LEADERSHIP

“
Strong clinical leadership is imperative to obtain
buy-in from key stakeholders in improvement
efforts, build a shared vision and support an
improvement culture…
Enlist Clinical Leadership
It is widely acknowledged that strong
leadership at all levels in the NHS is
required to achieve the ambition of
”
have the skills and knowledge to lead
with vision and creativity, create a
culture of innovation, and help to
shape and implement the strategic
Although it’s not always easy to
obtain, clinical leadership is crucial for
the ownership and sustainability of
service improvements and ongoing
Full transcripts of interviews with
individual site managers are
available to download at:
delivering gold standard health and direction of health care by clinical engagement. A significant www.improvement.nhs.uk/heart/
health services to patients and highlighting, influencing, proportion of all improvement cardiacrehabilitation
communities. There is much evidence communicating with, respecting and endeavours should be focused on
at a national and local level from both supporting others. They believe in the building the capacity for change and
primary, secondary and tertiary care task in hand and the importance of innovation in people and
that where there is effective clinical working across traditional organisations.
engagement and leadership, then organisational boundaries, whilst
innovation, modernisation, quality ensuring a constant focus on patient-
improvement and patient-focused centred outcomes.
care flourish. Effective clinical leaders


1. Engage with clinical leads from the outset and involve them in every step of the North West London Cardiac and Stroke Network
project so that they can share their expertise and experience, win over other clinicians The attainment of strong clinical leadership and good clinical engagement
and teams, and steer and implement change. Ensure that other stakeholders and from the outset
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 Background and context
brings together. The PPCI CR project has two clinical leads, Judith Edwards, the Senior Clinical Nurse
North West London Cardiac and Stroke Network Specialist who leads the project at Imperial College Healthcare NHS Trust and Dr Amarjit
Sethi, a Consultant Cardiologist from Ealing Hospital NHS Trust. Both clinical leads were
2. Designate a programme leader to each individual programme and give them the highly motivated to address the problem and were comfortable with cross-sector
responsibility for planning their service. working.
and North Lincolnshire Cardiac and Stroke Network Both clinical leads are strongly committed to the development of cardiac rehabilitation
across North West London and keen to facilitate uptake of CR by any means within their
3. Strong clinical leadership is imperative to obtain buy-in from key stakeholders in scope. They meet regularly with the CR service improvement manager for North West
improvement efforts, build a shared vision and support an improvement culture- London Cardiac and Stroke Network to review progress and discuss future plans for
particularly amongst other clinicians and frontline staff. Providers find it reassuring service development, demonstrating a proactive approach in identifying new ideas or
when commissioners see the need for clinical expertise in any review of service or solutions to any issues arising.
plans for service redesign and feel more confident that their voice will be heard.
NHS North of Tyne, North of England Cardiovascular Network The network hosts a Cardiac Rehabilitation Working Group. Judith Edwards and Dr
Amarjit Sethi are actively involved in formulating and agreeing the agenda for the
meetings, 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, the
service improvement manager and with staff ‘on the ground’, the project would not have
achieved the level of change and the sustained achievements it has demonstrated to
date.


5. COLLECT, ANALYSE AND MAKE USE OF ROBUST DATA

“
Use robust data to provide evidence to underpin
the need for service redesign and to demonstrate
achievements

Collect, Analyse and Make Use
of Robust Data
”
problem, focus your improvement
efforts, mobilise support and
Most improvement projects involve a
combination of qualitative and Full transcripts of interviews with
Capturing, interpreting and utilising resources and demonstrate if the quantitative approaches. This allows individual site managers are
good quality data is an essential resources, time and energy invested statistically reliable information available to download at:
element in planning, implementing in any improvement work represents obtained from numerical www.improvement.nhs.uk/heart/
and evaluating the success of any value for money. Most importantly, measurement to be backed up by cardiacrehabilitation
improvement project. Although ‘data’ when linked to the aims and and enriched by more in-depth
and ‘information’ are often used objectives of a project or service, it information about the experience of
interchangeably, data is effectively raw will enable you to understand, groups and individuals.
materials and unorganised facts that demonstrate and measure whether
when processed, organised and any change has resulted in an
structured and placed in context they improvement, the scale of the
become useful ‘information’. Data can improvement, and whether it’s
help you diagnose and define your sustainable.


1. A pilot of audit questions is imperative in order to check whether you are asking the Black Country Cardiovascular Network
right questions in the right way, otherwise you will not get comprehensive answers Pilot of a three month audit to ascertain why patients were not attending for
and the answers you do receive may be misleading. rehabilitation enabled further development and refinement of questions prior to
Black Country Cardiovascular Network a more comprehensive nine month audit

2. It is essential to have good quality data to be able to fully understand and Background and context
analyse a service. Concern had been expressed by organisations providing cardiac rehabilitation (CR)
Black Country Cardiovascular Network throughout the Black Country Cardiac Network (BCCN) that the national picture for
uptake of CR was not truly reflective of their experience. In addition they were aware of,
3. Conducting a comprehensive and rigorous audit to establish a baseline position, help
and wishing to comply with, the national emphasis to increase uptake to CR. In particular
understand if existing services are meeting the required standards, and provide real
they wanted to test out the difference between patients being offered, and then
data to back up any anecdotal evidence is an essential first step for any new project
declining CR, as opposed to CR not being offered and the reasons behind this.
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
The BCCN had already committed to the three month audit when the opportunity to join
improvements are realised.
the national project arose. Joining the national project gave an impetus to the audit,
North West London Cardiac and Stroke Network
allowing it to develop a more robust outlook, incorporating and increasing measures not
4. Use robust data to provide evidence to underpin the need for service redesign and to previously considered and raising the profile of CR in the health community. They saw the
demonstrate achievements. Be prepared to present these data in different ways to whole process as a means of informing commissioners about the current state of CR in
meet the needs and priorities of different stakeholders. the BCCN and steps being taken to address any issues.
Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network
Statistical analysis was undertaken at the end of the initial three month audit.
5. Use all available data to understand where you are now, to provide evidence of the This demonstrated a huge difference between patients not being referred to the service
achievement of standards, to monitor progress and to measure service improvement. in the first place as opposed to being offered the service and then declining. It became
Data should cover process, payments, activity and outcomes and be able to clear during the analysis that some of the paperwork indicated a non-referral when in
demonstrate return on investment and secure continued funding. Ensure that all reality, it was an agreement between the referring health care professional and the
relevant indicators and measures are built into your service specification from the patient that they shouldn’t be referred for what was often the perception that physical
outset and embedded in your service redesign efforts. capacity to exercise precluded referral eg severe arthritis. This bears out a general
Derbyshire County PCT misconception amongst some referrers that CR is ‘just about exercise’ rather than lifestyle
interventions and advice – which would also include some help with full exercise
6. Build sustainability into the service by understanding demand and capacity. programmes or adapted exercise according to need.
Additional findings, which helped to further develop and refine the questions for the nine
7. Understanding and collecting data is a vital component of service improvement and month audit, were around travel, uptake of female patients to CR and a need to clarify
redesign in order to establish a baseline and benchmark services, measure progress, and add in subsequent questions to the response ‘not interested’ in returns by referrers.
manage performance and avoid under-reporting. It is worth investing time and When analysing the statistical data it was apparent that this had to be done in context of
resource in ensuring that everyone recognises the need for robust data and the knowledge of the local catchment area in order to make the results meaningful.
systems to support data collection, analysis and submission.
NHS North of Tyne, North of England Cardiovascular Network Initial findings from the nine month audit, which is due to complete in May 2010, already
show improved referral and better data quality. A full and comprehensive review of the
8. Consider local data requirements – you may need to establish your own dataset to use data once the audit is complete will enable the service to be reviewed and further
concurrently with the NACR database depending on how you intend to use the data. developed.
NHS North of Tyne, North of England Cardiovascular Network


6. SPECIFY YOUR SERVICE REQUIREMENTS

“
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
Specify Your Service Requirements
A specification is a document
describing a commissioner’s needs,
which enables providers to propose an
Experience suggests that you will get”
what you ask for in the specification:
Errors in writing the specification may
affect end users and undermine your
The preferred option for most
specifications is to express
requirements as outcomes, i.e. what
you are aiming to achieve, rather than
Before signing off the specification, it’s
worth asking the question, ‘If everything
we asked for was provided, would we
have what we are really looking for’5?
appropriately costed solution to meet strategic aims. Conversely, omitting inputs or outputs. Although some
those needs. As a minimum, information may lead to assumptions outcomes may be intangible and more
specifications should set out the by the providers which may or may difficult to measure, an outcomes-
commissioner’s requirements, provide not be correct. A specification will also based specification allows providers
a shared understanding of each determine whether you achieve value greater flexibility to propose how they
party’s responsibilities and reflect for money: Over-specifying may result will meet the outcomes and is likely to
www.improvement.nhs.uk/heart/
users’ views. in paying over the odds and runs the elicit more innovative provision
cardiacrehabilitation
risk of stifling innovation by restricting tailored to the needs of service users
The effort and resources required to provider flexibility. On the other hand, and local communities4.
develop a specification will depend on under-specifying may result in
the value, complexity and risk of any expensive renegotiations of the
procurement but should not be contract or delays in completion.
underestimated.
Institute for Innovation and Improvement: Commissioning for Patient Pathways
4

Department for Children, Schools and Families (2009): Procurement Document 7: Specification Writing
5


1. Reviewing services, drawing up a broad strategy underpinned by a comprehensive Peninsula Heart and Stroke Network
service specification and obtaining universal acceptance across the health economy is The development of a new service model and detailed service specification for
not as straightforward as it may appear. Be prepared to spend a lot of time on the cardiac rehabilitation, supported by all PCTs across the South West Peninsula.
process and supporting documentation, consulting with and incorporating views from
all key stakeholders, so that the strategy is comprehensive and meets everyone’s Background and context
needs. Take every opportunity to win ‘hearts and minds’ – it will pay dividends in As with many areas across the country and despite the publication of the evidence, there
the long term. has always been patchy development of CR services both nationally and across the SW
Peninsula Heart and Stroke Network Peninsula. This is chiefly due to the fact that funds were subsumed by more pressing CHD
priorities such as the achievement of hard targets associated with revascularisation. At
2. Be prepared to invest considerable time and resources into the development of a this time there was no national tariff for CR making it difficult to understand the costing
robust and comprehensive service specification which effectively captures all needs implications. Furthermore, few NHS organisations have developed tight commissioning
and requirements. specifications for CR or have audit data enabling them to understand the exact cost of
Peninsula Heart and Stroke Network CR and what value is being delivered for their investment.
3. Establish and maintain robust systems for communication between commissioners and As a consequence, services were not given sufficient funding and appropriate resources.
providers to reduce anxieties and ambiguities in service specification development. Some providers became understandably protective of their services preventing innovative
ways 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 was
clear that finding more creative ways of ensuring equitable access to CR was vital to
secure appropriate commissioning of services.

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

The resulting report and recommendations propose a new and innovative service model
of CR with a vision to establish strong links with the broader public health prevention
programmes (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 key
performance indicators (KPIs) and quality markers to ensure equity of services and value
for money will be achieved.


7. COMMISSION EFFECTIVELY

“
It is essential to include commissioners in the initial
review of services and in any plans for future
service redesign

Commission Effectively
In simple terms, commissioning is the
”
interlinked activities ranging from
assessing population needs and
In doing so, commissioners are
expected to proactively seek and build Full transcripts of interviews with
process by which local organisations prioritising health outcomes and continuous and meaningful individual site managers are
decide how to spend available funds investment, to developing, stimulating engagement with the public and available to download at:
to ensure that the health and care and managing markets and service patients to shape services and improve www.improvement.nhs.uk/heart/
services provided effectively meet the providers. In this respect it is health and with clinicians to inform cardiacrehabilitation
needs of the population and deliver incumbent on commissioners as local strategy, and drive quality, service
better outcomes for patients based on leaders of the NHS to work design and intelligent resource
local priorities. collaboratively with a wide range of utilisation6.
partners both within and outside the
Commissioning is not just about NHS to commission services that
procuring products and services; it’s a optimise health gains and reductions
more complex process which involves in health inequalities as well as
a broader range of separate but providing value for money.

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


1. Explore opportunities to promote and seek innovation in commissioning and the South London Cardiac and Stroke Network
provision of CR services from the full range of providers (NHS and non-NHS). The development of a set of core commissioning outcomes for cardiac
Peninsula Heart and Stroke Network rehabilitation (CR) at a pan-London level

2. Work very closely with Commissioners from the beginning and be sure that you are Background and context
meeting their aims as well. The network identified that clinicians lacked a sound understanding of the
Peninsula Heart and Stroke Network commissioning process for CR and also that commissioners did not fully understand
outcomes for cardiac rehabilitation. Moreover, there was no common approach to
3. Be prepared to manage your market. Investing resources in informing and developing commissioning for CR across the sector and that this was common throughout all
potential providers reaps rewards in terms of increasing understanding of the London networks.
procurement process and the service specification.
Peninsula Heart and Stroke Network In view of this, the network organised and facilitated a pan-London event for
commissioners and clinicians. The primary purpose of the workshop was to engage with
4. Establish and maintain mechanisms to encourage continuous dialogue between
clinical and commissioning colleagues in the development of a common set of core
commissioners and providers and ensure this happens right from the outset. If this
outcomes to be used when commissioning CR.
process is not in place or there are delays in commencing regular meetings, anxieties
may surface which then take time to resolve. The event was very well-received and generated a great deal of positive feedback from
NHS North of Tyne, North of England Cardiovascular Network commissioners and clinicians alike.
5. Commissioners need to understand the current service in order to develop ideas for a The core outcome measures- which are now in their third and hopefully final draft- focus
new service. Transparency, an understanding of and willingness to work with providers on quality of life, patient goals and patient satisfaction. Stakeholders have agreed that CR
helps to build and sustain active engagement in the change process. programmes 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 from
6. It is essential to include commissioners in the initial review of services and in any plans benchmarking patient satisfaction/ experience across the patch. With this in mind, a
for future service redesign. patient experience questionnaire is currently being developed by and for CR patients. This
fits in well with the quality strand of the QIPP agenda.
7. Make sure that everyone is aware of what is on the horizon and be alert to how In addition to the successful identification of core pan-London outcome measures for CR,
embarking on procurement might affect the involvement of stakeholders. Half way in the workshop also highlighted the lack of formal learning opportunities for CR staff
to the procurement process in Derbyshire the PCT became aware of potential conflicts within the Network. In view of this, the Network is planning to hold a similar pan-London
of interest with clinicians and managers from provider Trusts already engaged in the event on an annual basis, as well as regular educational sessions for CR teams at a
service redesign efforts. This highlighted the importance of the need to be prepared to network level.
manage relationships in a different way whilst maintaining the enthusiasm and
commitment of key stakeholders in pathway redesign. The network is also hoping to incorporate the local measures into the National Audit of
Derbyshire County PCT Cardiac Rehabilitation (NACR), though the current inability to produce a Network-level
report is seen as a risk to delivery.


8. USE RESOURCES WISELY

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

Use Resources Wisely
While the economic landscape around
eliminating waste, more effective
partnership working and the pursuit
Innovation and service redesign in
particular- along with prevention- are
”
redesign efforts should follow a
structured methodology but, more
us has changed dramatically in recent of evidence-based practice. As viewed as being key enablers for importantly, should be clinically led
months, the vision for an NHS with discussed later in this document, it is achieving quality and productivity and promote effective team working.
quality at its heart remains the same. now more important than ever to gains and improving outcomes and
Far from being an accessory ensure the use of NHS resources is efficiency in health. The key principles
programme, the Quality, Innovation, geared towards providing clinically of service redesign in this respect
Productivity and Prevention (QIPP) effective and high quality care, comprise a focus on the patient
agenda has created a new backdrop delivering value for money and better journey and improving patient
for the NHS and has led to a greater and sustainable outcomes for local experience and outcomes
www.improvement.nhs.uk/heart/
focus on efficiency, productivity, people. NHS organisations can achieve accompanied by meaningful
cardiacrehabilitation
quality and value. this not only through prudent involvement and engagement of all
financial management, strategic key stakeholders, including clinicians,
Delivering improvements in a commissioning and good governance, managers and patients. Service
resource-constrained environment but also through shrewd management
requires an even bigger emphasis on of people, assets and other resources.


1. Consider using training to increase skills in marketing techniques so that patients and Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East
referrers fully understand the benefit of undertaking a rehabilitation course. Yorkshire and North Lincolnshire Cardiac and Stroke Network
Black Country Cardiovascular Network Patients no longer have to wait to join the phase three CR programme in the
hospital or community
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. Background and context
Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network In an effort to tackle the historical three month long waiting time, and to ensure that
patients received timely and appropriate access through triage to phase three CR, the CR
3. Ensure that staff are afforded sufficient time to devote to discussing and agreeing
team worked alongside the local cardiac network to map the existing service and
individual management plans with patients and responding to their individual needs and
undertake a demand and capacity exercise.
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 Process mapping identified that the major bottleneck in the process was the need for
experience and the quality of patient care, as well as improving overall service efficiency. patients to attend clinic appointments so that doctors could make an assessment on the
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac patient ensuring they were fit to commence the CR programme. In some cases, patients
and Stroke Network
were waiting several months to be seen before being deemed fit to commence phase
4. Investigate interventions and services aimed at tackling health inequalities and improving three CR, and then being referred back to the CR service. The team also identified that
health in deprived areas as these may help identify other potential sources of funding. clinic appointments and CR sessions were often cancelled due to Bank Holidays, study
Peninsula Heart and Stroke Network days and so on.

5. Don’t duplicate systems and/ or services – find out what is already available whether public In view of the findings, the team redesigned the service. Instead of waiting for a clinic
or privately provided, and forge links where appropriate. appointment, patients are now given a pre-assessment appointment within two weeks of
Peninsula Heart and Stroke Network being considered fit to commence phase three. At pre-assessment, patients are assessed
by the nurses and the exercise instructor, and if deemed suitable are given a definitive
6. As a project manager be focussed on what it is you are trying to achieve – be clear about start date for phase three - usually within a week but sometimes the next day! Any
your role and the role of others you are working with to achieve redesign. patients deemed unsuitable at pre-assessment are given a clinic appointment prior to
Peninsula Heart and Stroke Network commencing the exercise programme and/or CR, staff are given the opportunity to
discuss the case with the consultant.
7. Consider all eventualities and think about how to deal with any findings uncovered during a
pilot phase. In this case, the skills competency audit identified some unexpected clinical Work is now planned to mitigate the effect Bank Holidays have on the service and there
governance issues which could not be discussed further without compromising the is a strict ‘no cancellation’ policy coupled with a greater focus on forward planning.
confidentiality of staff involved in the pilot. By providing each audit participant with a Patients are also encouraged to take more responsibility for their rehabilitation - sessions
personal summary report/ audit feedback, the individuals concerned were able to raise missed for any reasons other than ill-health are no longer ‘tagged on’ to the end of the
training and development needs in the context of personal performance reviews. programme. Patients have responded well to this and take responsibility for their own
South London Cardiac and Stroke Network rehabilitation, ensuring they attend their planned sessions and exercising up to five times
a week on their own according to recommended guidelines.
8. Establish good relationships with the local council/ exercise providers so that you can flex
the system and provide choice for patients. Partnership working with the local council and exercise instructors and conducting case
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire conferences with the multi-disciplinary team on a weekly basis has enabled the service to
and North Lincolnshire Cardiac and Stroke Network fast track suitable patients into phase four rehabilitation, releasing capacity for the phase
three course.
9. Timetable weekly communication meetings for all team members to discuss issues and
propose solutions.


9. COLLABORATE AND NETWORK

“
The National Priorities Project has been an opportunity
to network and share information with other cardiac
rehabilitation centres locally and nationally to
promote best practice
Collaborate and Network
The vision for the NHS in England is
one in which patients and the public
are enabled to become active partners
to step outside traditional
”
commissioners they allow individuals

organisational, cultural, political and
geographical boundaries and work in
voice in the local health economy to
enable frontline staff to secure the
changes they need to deliver for their
patients.
and not just passive recipients of care. a co-ordinated manner to ensure www.improvement.nhs.uk/heart/
This, in turn involves the active equitable provision of high-quality, By making both formal and informal cardiacrehabilitation
engagement of staff and collaboration clinically effective services. Networks networks visible, managers can
across the NHS and partner play a key role in fostering innovation systematically assess and support
organisations. and bring in ideas from other areas strategically important collaboration.
and initiatives to support service
Networks- formal or informal- have improvement and redesign and in
immense potential to improve the way doing so can help the NHS spread and
that services are planned, sustain effective concepts,
commissioned and delivered for both improvement ideas and processes for
staff and patients. Bringing together the common good. Most importantly,
clinicians, managers and networks can provide a powerful


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