Cardiac rehabilitation service

Commissioning guide
Implementing NICE guidance

March 2008

1
Cardiac rehabilitation service ........................................................................... 3
Commissioning a cardiac rehabilitation service ............................................... 4
Benefits ........................................................................................................ 5
Key clinical issues ........................................................................................ 5
National priorities.......................................................................................... 6
Specifying a cardiac rehabilitation service ....................................................... 7
Service components ..................................................................................... 7
Systematically identifying and actively engaging people potentially eligible
for cardiac rehabilitation ............................................................................ 7
Developing a high-quality comprehensive cardiac rehabilitation service .. 8
Determining local service levels for a cardiac rehabilitation service............... 11
Benchmarks for a standard population ....................................................... 11
Further information ..................................................................................... 11
Assumptions used in estimating a population benchmark ............................. 13
Hospital episode statistics data and general practice data ......................... 13
Published research..................................................................................... 14
Expert clinical opinion ................................................................................. 14
Conclusions ................................................................................................ 15
Table 1 Assumptions used in the population benchmark for cardiac
rehabilitation based on 2006/7 hospital activity data and expert clinical
opinion .................................................................................................... 15
References ................................................................................................. 16
The commissioning and benchmarking tool ................................................... 17
Identify indicative local service requirements ............................................. 17
Review current commissioned activity ........................................................ 17
Identify future change in capacity required ................................................. 17
Model future commissioning intentions and associated costs .................... 17
Ensuring corporate and quality assurance ..................................................... 19
Local quality assurance .............................................................................. 19
Further information ..................................................................................... 20
Topic-specific Advisory Group ....................................................................... 22

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Cardiac rehabilitation service
This commissioning guide provides support for the local implementation of
NICE clinical guidelines through commissioning, and is a resource to help
health professionals in England to commission an effective cardiac
rehabilitation service.

This commissioning guide should be read in conjunction with the following

NICE guidance:

NICE clinical guideline CG48 MI: secondary prevention secondary

prevention in primary and secondary care for patients following a
myocardial infarction.
The clinical guideline covers clinical and cost effectiveness in detail and
underpins the content of this guide.

The guide:

makes the case for commissioning a cardiac rehabilitation service

specifies service requirements
helps you determine local service levels
helps you ensure corporate and quality assurance.

The full text of this commissioning guide is accessed from the navigation
menu on the right hand side of the screen. The associated commissioning tool
is available until 25 June 2010 to primary care organisations in England who
are already registered to use the tool. New registrations for the existing
commissioning tool will not be possible after 31 March 2010

From 1 April 2010 the new freely available commissioning and benchmarking
tool can be downloaded here. There is no need to register.

We are keen to improve the commissioning guides in order to better meet the
needs of commissioners. Please send us your ideas for future topic-specific
guides or other comments.

Read the NICE disclaimer for information on the use and accuracy of content
on the NICE website.

Topic-specific Advisory Group: cardiac rehabilitation service

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Commissioning a cardiac rehabilitation service
Cardiac rehabilitation is a set of services that enables people with coronary
heart disease (CHD) to have the best possible help (physical, psychological
and social) to preserve or resume their optimal functioning in society. There is
evidence that cardiac rehabilitation reduces the risk of total and cardiac
related mortality, subsequent revascularisation and occurrence of non-fatal
myocardial infarction (MI). Evidence also suggests that it results in improving
peoples ability to work, their physical capacity and their perceived quality of
life. Cardiac rehabilitation is an established therapy and comprises mainly of
supervised exercise training, relaxation and education.

Cardiac rehabilitation should not be regarded as an isolated form or stage of

therapy, but be integrated within secondary prevention services. Cardiac
rehabilitation services are no longer exclusively hospital based; emphasis is
placed on helping patients become active self-managers of their condition and
this can involve hospital, home and community based cardiac rehabilitation
programmes, all of which are effective. Collaboration between primary and
secondary care services is vital in order to achieve the best cardiac
rehabilitation outcomes.

Cardiac rehabilitation is recommended, in NICE clinical guideline CG48 on MI:

secondary prevention, as an appropriate intervention for people following a
hospital admission for MI. This supports the National service framework for
coronary heart disease, which states that every hospital in England should
ensure that more than 85% of people discharged from hospital with acute MI
or after coronary revascularisation are offered cardiac rehabilitation. Once
trusts have an effective system for identifying, treating and following up people
who have survived an MI or who have undergone coronary revascularisation
(coronary artery bypass graft and percutaneous coronary intervention) they
should extend their rehabilitation services to people admitted to hospital with
other manifestations of CHD.

Therefore, although this commissioning guide focuses on cardiac

rehabilitation for patients post MI, commissioners may wish to consider that
such services can also provide benefits for people with stable angina or heart
failure, and people undergoing revascularisation (before or after surgery,
percutaneous coronary intervention or both) or other specialised interventions
(for example, heart transplant and surgery to fit implantable cardiac
defibrillators).

Currently, many people who might benefit do not receive adequate cardiac
rehabilitation. The extent, nature and cost of provision varies dramatically
around the country with some services developing in a haphazard way with no
core funding and relying on charitable donations and time borrowed from
various hospital departments. The cost of cardiac rehabilitation varies
enormously, from 17 to 2186 per patient, despite it being highly cost
effective at around 550 per patient. There are also marked inequalities in the
way people access the services that are available. Women, minority ethnic
groups, the elderly and people with more severe CHD are all under-

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represented among users of rehabilitation services. Furthermore, in many
parts of the country those that are ready to start a rehabilitation programme
may have to wait for several weeks, thereby delaying their return to normal
life.

Benefits
The potential benefits of robustly commissioning an effective comprehensive
cardiac rehabilitation service include:

greater survival for people with CHD who participate in

comprehensive cardiac rehabilitation
improving exercise tolerance and quality of life for people with mild
to moderate heart failure
reducing unplanned hospital admissions
increasing choice for patients by offering hospital, home and/or
community based rehabilitation programmes
improving clinical outcomes through enabling people to become
active self managers of their condition
providing efficient clinical management at all four phases of the
patient journey as recommended in National service framework for
coronary heart disease modern standards and service models.
Chapter 7: Cardiac rehabilitation
reducing inequalities and improving access for those groups less
likely to access cardiac rehabilitation services, including people from
black and minority ethnic groups, women, people from rural
communities and people with mental and physical health comorbidities
better value for money, through helping commissioners to manage
their commissioning budgets more effectively this may include
opportunities for clinicians to undertake local service redesign to meet
local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective comprehensive cardiac
rehabilitation service are:

actively identifying all people potentially eligible for cardiac

rehabilitation and encouraging them to take part in cardiac
rehabilitation prior to hospital discharge
assessing an individuals risk and need for cardiac rehabilitation
and developing individualised plans to meet those needs in line
with NICE clinical guideline CG48 on MI: secondary prevention and the
British Association for Cardiac Rehabilitation document Standards and
core components for cardiac rehabilitation
providing a quality assured service.

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National priorities
National priorities and initiatives relevant to commissioning a cardiac
rehabilitation service include:

National service framework for coronary heart disease modern

standards and service models. See chapter 2, Preventing coronary
heart disease in high risk patients, and chapter 7, Cardiac
rehabilitation.
The Care closer to home initiative outlined in chapter 6 of the white
paper Our health, our care, our say.
Commissioning framework for health and well-being.
World class commissioning.
The NHS in England: The operating framework for 2009/10.
Considering the impact of patient choice.
The Expert patients programme.
A stronger local voice: a framework for creating a stronger local voice
in the development of health and social care services.
Implementation of NICE clinical and public health guidelines. These are
core standards, and performance against these standards will be
assessed by the Care Quality Commission in line with Standards for
better health.

Although many or all of these priorities may be relevant to the services

nationally, your local service redesign may address only one or two of them.

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Specifying a cardiac rehabilitation service

Service components
The key components of a cardiac rehabilitation service are:

systematically identifying and actively engaging people potentially

eligible for cardiac rehabilitation
developing a high-quality comprehensive cardiac rehabilitation service.

Systematically identifying and actively engaging people potentially

eligible for cardiac rehabilitation
Poor referral, take-up and attendance have been identified as problems facing
cardiac rehabilitation services in the UK. There are several reasons for the
lower than expected levels of participation. These include a lack of
engagement (people not invited to attend cardiac rehabilitation), low levels of
referral, scarcity of service provision and poor take-up due to practical
reasons (for example, location and time of the session).

NICE clinical guideline CG48 on MI: secondary prevention makes the

following recommendations for improving engagement and take-up of cardiac
rehabilitation services.

Healthcare professionals, including senior medical staff involved in

providing care for patients after an MI, should actively promote cardiac
rehabilitation. All patients (regardless of their age) should be given
advice about and offered a cardiac rehabilitation programme with an
exercise component. Patients with left ventricular dysfunction who are
stable can safely be offered the exercise component of cardiac
rehabilitation.
Cardiac rehabilitation should be equally accessible and relevant to all
patients after an MI, particularly people from groups that are less likely
to access the service. These include people from black and minority
ethnic groups, older people, people from lower socioeconomic groups,
women, people from rural communities and people with mental and
physical health comorbidities.
Cardiac rehabilitation programmes should include an exercise
component designed to meet the needs of older patients or patients
with significant comorbidity. Any transport problems should be
addressed.
Reminders such as telephone calls, telephone calls in combination with
direct contact from a healthcare professional, and motivational letters
should be used to improve uptake of cardiac rehabilitation.
Healthcare professionals should ask patients whether they would prefer
single-sex classes or mixed classes.

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Where cardiac rehabilitation services have been adequately resourced and
where they have systematically identified people and adopted a structured
approach to their work, the numbers of people treated have increased. Trust-
wide protocols that specify the arrangements for identifying appropriate
patients and that specify agreements with primary care trusts about the
groups of patients who are to be offered cardiac rehabilitation can be found in
the National service framework for coronary heart disease. Once trusts have
an effective system for identifying, treating and following up people who have
survived an MI or who have undergone coronary revascularisation
commissioners may wish to consider extending cardiac rehabilitation services
to include people with stable angina and heart failure, and those who are
undergoing specialised interventions such as cardiac transplant and
implantable cardioverter defibrillators (see Implantable cardioverter
defibrillators for arrhythmias NICE technology appraisal 95).

In addition cardiac rehabilitation services may need to accept referrals from

clinicians working in other localities; these may include people who have been
admitted to hospital far from where they live, for example, those having
surgery at a specialist centre or people who have suddenly become unwell
while away from home.

Developing a high-quality comprehensive cardiac rehabilitation service

A prime aim of a cardiac rehabilitation programme is to provide a set of
services tailored to the needs of each patient based on a comprehensive
assessment of their cardiac risks. The range of options is described in NICE
clinical guideline CG48 on MI: secondary prevention and include:

health education and information

advice on lifestyle: diet and weight management, physical activity and
exercise, smoking cessation and alcohol consumption
psychological and social support
cultural and vocational needs
family and carer needs.

Patients should be encouraged to attend all services appropriate to their

clinical needs and should not be excluded from the entire programme if they
choose not to attend certain components.

Some patients may benefit from a home based comprehensive cardiac

rehabilitation programme validated for patients who have had an MI (such as
The Edinburgh heart manual) that incorporates education, exercise and
stress management components with follow-ups by a trained facilitator. It
should be offered to patients as part of a menu based approach but should
not be used to replace a multi-disciplinary hospital based programme, as
some patients prefer to exercise in hospital and others will have complex
conditions that need specialist assessment. A home based programme
produces similar gains to hospital programmes and has been shown to be
preferred by many patients. The term home-based programme is applied to a

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variety of methods but any programme purchased should have a published
evidence base and attend to lifestyle change and psycho-social adjustment.

The British Association for Cardiac Rehabilitation document Standards and

core components for cardiac rehabilitation recommends a multidisciplinary
approach to cardiac rehabilitation consisting of trained and competent staff.
These would include a service lead with overall responsibility for the service, a
cardiac specialist nurse, physiotherapist, dietitian, occupational therapist,
administrator and part-time designated clinical lead (for example, a
cardiologist or GP with a special interest in cardiology). The team should also
include, where appropriate, a pharmacist and a physical activity/exercise
specialist, and incorporate referral to a psychologist.

Commissioners may wish to consider commissioning a district wide cardiac

rehabilitation service across the four phases described in the National service
framework for coronary heart disease. Cardiac rehabilitation should begin as
soon as possible after someone is admitted (or planned to be admitted) to
hospital with coronary heart disease (CHD) (phase 1), continue through the
early post discharge period (phase 2) and the formal rehabilitation service
(phase 3) and extend into long term maintenance (phase 4). Primary care
trusts, local authorities and the voluntary sector should agree the range and
availability of services that can be drawn on for cardiac rehabilitation. For
example, local authority leisure centres, church halls or other easily
accessible public venues may be appropriate for cardiac rehabilitation
sessions, and appropriately trained local authority staff can play a useful role
in supervising physical activity and supporting exercise-on-prescription
schemes.

Commissioners may wish to consider commissioning a cardiac rehabilitation

service in a number of different ways, and mixed models of provision may be
appropriate across a local health economy. Commissioners may also wish to
collaborate with the local cardiac network to ensure a strategic approach to
service development.

There are many examples and models of cardiac rehabilitation services.

Cardiac rehabilitation, supported by the British Heart Foundation, provides
names and addresses of cardiac rehabilitation services throughout the UK. A
cardiac rehabilitation service in Cornwall demonstrates that national service
framework targets for cardiac rehabilitation and secondary prevention can be
achieved in patients who survive a MI by integrating rehabilitation services
(home and hospital) with secondary prevention clinics in primary care. Nurse
led clinics in primary care facilitate long term structured care and optimal
secondary prevention. Payments for these clinics are now included in the new
GP contract as part of the Quality and outcomes framework. This example is
offered to share practice and NICE makes no judgement on the compliance of
this service with its guidance.

Local stakeholders, including service users, carers and family members

should be involved in determining what is needed from a cardiac rehabilitation
service in order to meet local needs. The service should be patient-centred
and integrated with other elements of care for people/patients with CHD.

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The service specification needs to consider:

the required competencies of, and training for, staff responsible for
providing the service
the expected number of patients (this should take into account how
quickly any changes in service provision are likely to take place)
ease of access and service location; commissioners should engage
with service users and other relevant individuals and organisations
locally
care and referral pathways
information and audit requirements, including IT support and
infrastructure
planned service improvement, including redesign, quality, equitable
access, and referral-to-treatment times
service monitoring criteria.
Useful sources of information may include:

The NICE shared learning database offers examples of how

organisations have implemented NICE guidance locally.
Implementation advice for NICE clinical guideline CG48 on MI:
secondary prevention.
NICE technology appraisal guidance 95: Implantable cardioverter
defibrillators for arrhythmias.
Scottish Intercollegiate Guidelines Network clinical guideline 57:
Cardiac rehabilitation.
Standards and core components for cardiac rehabilitation produced by
the British Association for Cardiac Rehabilitation.
Heart Improvement Programme cardiac networks supports the
development of cardiac networks and ensures the spread of service
improvements.
The Map of medicine provides an information resource that visually
organises the latest evidence and best practice guidelines.
Heart Improvement Programme.
Prevention, treatment and rehabilitation of cardiovascular disease in
South Asians provides advice on prevention, treatment and
rehabilitation of CHD patients, especially tailored to South Asian
patients.
Heart disease and South Asians: delivering the national service
framework for coronary heart disease.

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Determining local service levels for a cardiac
rehabilitation service

Benchmarks for a standard population

Available data suggest that the standard benchmark rate for a cardiac
rehabilitation service for all the conditions/procedures listed in the
commissioning section of this guide is 0.20%, or 200 per 100,000, population
per year.

For a standard primary care trust population of 250,000, the average

number of people requiring cardiac rehabilitation would be 500 per year
(0.20% of the population).

For an average practice with a list size of 10,000, the average number of
people requiring cardiac rehabilitation would be 20 per year (0.20% of the
population).

The estimates used in the calculation of the benchmark for cardiac

rehabilitation are provided by the topic-specific advisory group; they are based
on best practice and are the proportions that could be achieved given optimal
service design.

This service is likely to fall under the programme budgeting category 210A
(problems of circulation coronary heart disease).

Examine the assumptions used in estimating these figures.

Use the cardiac rehabilitation service commissioning and benchmarking tool

to determine the level of service that might be needed locally and to calculate
the cost of commissioning the service using the indicative benchmark and/or
your own local data.

Further information
Sources of further information to help you in assessing local health needs and
reducing health inequalities include:

Annex A of the Commissioning framework for health and well-being

outlines the process and data needed to undertake a joint strategic
needs assessment.
Department of Health Delivering quality and value focus on
benchmarking.
NICE Health equity audit learning from practice briefing.
The No delays achiever provides access to service improvement tools
aimed at reducing time between referral and treatment.

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 The Practice-based commissioning comparators reporting service
provides access to a range of indicators and activity data at practice
level, enabling a better understanding of local commissioning activity,
referral patterns and outcomes.
The Disease management information toolkit (DMIT) is a good-
practice tool for decision-makers, commissioners and deliverers of care
for people with long-term conditions, which presents data on conditions
that contribute to high numbers of emergency bed days. It models the
effects of possible interventions that may be commissioned at a local
level and helps users to consider the likely impact of commissioning
options.
The PBS diabetes population prevalence model may be useful in
modelling the proportion of undiagnosed diabetes in a population, and
assessing future demand for services.
Disease prevalence models produced by the Association of Public
Health Observatories (APHO) provide PCT-level prevalence estimates
for hypertension and coronary heart disease.
PARR (Patients at risk of re-hospitalisation) is a risk prediction system
for use by primary care trusts to identify patients at high risk of hospital
re-admission.
PRIMIS+ provides support to general practices on information
management, recording for, and analysis of, data quality, plus a
comparative analysis service focused on key clinical topics.

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Assumptions used in estimating a population
benchmark
The assumptions used in estimating a population benchmark rate for new
referrals into a cardiac rehabilitation service are based on the following
sources of information:

Hospital episode statistics and general practice data to establish

the proportion of the population discharged alive per year following an
acute admission for a myocardial infarction (MI) or heart failure; and
after admission for revascularisation, heart transplant or implantable
cardiac defibrillators (ICD); and the proportion of the population
identified in the community with angina per year
published research on cardiac rehabilitation
expert clinical opinion of the topic-specific advisory group, based on
experience in clinical practice and literature review.

Hospital episode statistics data and general practice data

The Hospital episode statistics (HES) database contains details of all
admissions to NHS hospitals in England. It includes private patients treated in
NHS hospitals, patients who were resident outside England and care
delivered by treatment centres (including those in the independent sector)
funded by the NHS.

The analysis of the data from HES suggests that in 2006/07 0.12%, or 120
per 100,000 population, were discharged alive following an acute admission
for an MI and could therefore be given advice about and offered a cardiac
rehabilitation programme with an exercise component.

HES analysis in 2006/07 for other patient groups that may be suitable for
referral for cardiac rehabilitation following admission to hospital suggests that:

0.02%, or 20 per 100,000 population, were discharged alive following

percutaneous coronary intervention (PCI)
0.04%, or 40 per 100,000 population, were discharged following a
coronary artery bypass graft (CABG)
0.004%, or 4 per 100,000 population, were discharged following
implant of a cardiac defibrillator (ICD)
0.07%, or 70 per 100,000 population, were discharged alive following
an acute admission for heart failure.
People who had multiple admissions in the year, and people who had more
than one of the procedures and/or diagnoses were counted just once.

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Other groups that may benefit from cardiac rehabilitation include people who
have received heart transplants. The rate of heart transplants in the
population per year is small, around 3.3 per million.

People with stable angina may also be suitable for cardiac rehabilitation. On
the basis of data from IMS disease analyzer, a database that holds data on a
sample of GP practice databases, the annual incidence of diagnosed angina
that is, the average detection rate of new cases is 0.05% per year. This is
likely to be an underestimate of the need among this group, as many people
with diagnosed angina will have not been offered cardiac rehabilitation.

Published research
The NICE clinical guideline CG48 on MI: secondary prevention states that all
patients after an MI (regardless of their age) should be given advice about and
offered a cardiac rehabilitation programme with an exercise component.

Poor referral, take-up and attendance have been identified as problems facing
cardiac rehabilitation services in the UK[1],[2]. There are several reasons for the
lower than expected levels of participation. These include a lack of
engagement (people not invited to attend cardiac rehabilitation), low levels of
referral, scarcity of service provision, and poor take-up due to practical
reasons (for example, location and time of the session).

A 2004 health technology assessment Provision, uptake and cost of cardiac

rehabilitation programmes: improving services to under-represented groups
suggested that take-up of cardiac rehabilitation could be improved by
addressing the barriers to take-up (see Specifying a cardiac rehabilitation
service).

It is assumed that optimal service design would lead to an increase in take-up

and attendance in cardiac rehabilitation, and that those services with current
high levels of take-up and attendance may be operating closer to optimal
service design.

Currently around 55% of people who are invited or referred to cardiac

rehabilitation attend; however, estimates vary between 35% and 80% across
services. Therefore the optimal take-up of cardiac rehabilitation could be
around 80% or more.

Expert clinical opinion

The consensus opinion of the topic-specific advisory group was:

on average, around 8090% of people post MI should be suitable for

referral to a cardiac rehabilitation service, of which around 80% could
optimally take up the offer, providing that current barriers are
addressed
the majority of people post revascularisation (CABG and PCI) and ICD
implant would be suitable for referral for cardiac rehabilitation, and the
take-up of those referred would be around 85%

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 on average, around 7080% of people with heart failure would be
suitable for cardiac rehabilitation, and the take-up of those referred
would be around 6080%
the numbers of people presented within the commissioning and
benchmarking tool and used to estimate the population benchmark
may be an underestimate of the need, because some people may
require more than one course of cardiac rehabilitation in the year.
The estimates on the take-up and referral of cardiac rehabilitation provided by
the topic-specific advisory group are based on best practice and are the
proportions that could be achieved given optimal service design.

Conclusions
Based on the epidemiological data and other information outlined above, it is
concluded that 0.20% of the population would be suitable for referral to a
cardiac rehabilitation service. This is based on the following assumptions (see
also table 1):

the percentages of the population discharged alive for the indicated

conditions or following a revascularisation procedure or ICD implant
the mid-points of the ranges for suitability for cardiac referral and
expected optimal take-up of services under ideal circumstances
suggested by the topic-specific advisory group
the suitability for cardiac rehabilitation among people discharged alive
after an MI, revascularisation, heart failure, angina and ICD
implantation based on the mid-points suggested by the topic-specific
advisory group
the diagnosed incidence of angina in the population of around 0.05%
per year.

Table 1 Assumptions used in the population benchmark for cardiac

rehabilitation based on 2006/7 hospital activity data and expert clinical
opinion

Percentage
Percentage Percentage
Combination (optimal) of
of (optimal) of
of referral discharged
Percentage of discharged population
and optimal population
population population suitable for
Diagnosis/procedure take-up who take up
discharged alive in suitable for referral who
(percent) cardiac
2006/07 cardiac take up
that is, rehabilitation
rehabilitation cardiac
attendance based on
referral rehabilitation
2006/7 data

15
Myocardial infarction 0.12 85 80 68 0.082

Percutaneous
coronary 0.02 100 85 85 0.017
intervention

Coronary artery
bypass graft 0.04 100 85 85 0.034

Heart failure 0.07 75 70 0.037

53
Implant of a cardiac
defibrillator 0.004 100 85 0.0034
85

Therefore the population benchmark for a cardiac rehabilitation service is

estimated to be 0.20%.

Use the cardiac rehabilitation service commissioning and benchmarking tool

to determine the level of service that might be needed locally and to calculate
the cost of commissioning the service using the indicative benchmark and/or
your own local data.

References
1. Bethell H, Evans J, Malone S et al. (2005) Problems of cardiac
rehabilitation coordinators in the UK: are perceptions justified by facts? British
Journal of Cardiology 12: 3728.

2. Beswick AD, Rees K, Griebsch I et al. (2004) Provision, uptake and cost of
cardiac rehabilitation programmes: improving services to under-represented
groups. Health Technology Assessment 8: 1166.

16
The commissioning and benchmarking tool
Download the cardiac rehabilitation service commissioning and
benchmarking tool.

Use the cardiac rehabilitation service commissioning and benchmarking tool

to determine the level of service that might be needed locally and to calculate
the cost of commissioning the service, as described below.

Identify indicative local service requirements

The indicative benchmark for a cardiac rehabilitation service is 0.20% per
year.

The commissioning and benchmarking tool helps you to assess local service
requirements using the indicative benchmark as a starting point. With
knowledge of your local population and its demographic, you can amend the
benchmark to better reflect your local circumstances. For example, if your
population is significantly younger or older than the average population, or has
an ethnic composition different from the national average, or has a
significantly lower or higher rate of coronary heart disease, you may need to
provide services for relatively fewer or more people.

Review current commissioned activity

You may already commission a cardiac rehabilitation service for your
population. You can download your own up-to-date secondary care activity
data into the tool, and data specifications and user notes are provided to help.
You can review and amend the downloaded data for your population to
calculate the service levels and cost of the service you currently commission.
When commissioning outpatient appointments or activity outside of secondary
care, for example in the community, the tool provides you with tables that you
can populate to help you calculate your total current commissioned activity
and costs.

Identify future change in capacity required

Using the indicative benchmark provided, or your own local benchmark, you
can use the commissioning and benchmarking tool to compare the activity
that you might need to commission against your current commissioned
activity. This will help you to identify the future change in capacity required.
Depending on your assessment, your future provision may need to be
increased or decreased.

Model future commissioning intentions and associated costs

You can use the commissioning and benchmarking tool to calculate the
capacity and resources needed to move towards the benchmark level, and to
model the required changes over a period of 4 years.

17
Use the tool to calculate the level and cost of activity you intend to
commission and to consider the settings in which the cardiac rehabilitation
service may be provided, comparing the costs of commissioning the service
across the various settings. The tool is pre-populated with data on the
potential recurrent and non-recurrent cost elements that may need to be
considered in future service planning, which can be reviewed and amended to
better reflect your local circumstances.

Commissioning decisions should consider both the clinical and economic

viability of the service, and take into account the views of local people.
Commissioning plans should also take into account the costs of monitoring
the quality of the services commissioned.

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Ensuring corporate and quality assurance
Commissioners should ensure that the services they commission represent
value for money and offer the best possible outcomes for patients.
Commissioners need to set clear specifications for monitoring and assuring
quality in the service contract.

Commissioners should ensure that they consider both the clinical and
economic viability of the service, and any related services, and take into
account patients and carers views and those of other stakeholders when
making commissioning decisions.

A cardiac rehabilitation service needs to:

be effective and efficient

be responsive to the needs of patients and carers
provide treatment and care based on best practice, as defined in
NICE clinical guideline CG48 on myocardial infarction (MI): secondary
prevention
deliver the required capacity
be integrated closely with other services in primary and secondary
care, ensuring that people requiring cardiac rehabilitation receive
continuity of care at all four phases of the patient journey
define agreed criteria for referral, local protocols and the care
pathway for patients requiring cardiac rehabilitation
be patient-centred and provide equitable access, ensuring that
patients are treated with dignity and respect, are fully informed about
their care and are able to make decisions about their care in
partnership with healthcare professionals
audit various components and submit this information to the National
audit of cardiac rehabilitation
demonstrate how it meets requirements under equalities
legislation
demonstrate value for money.

Local quality assurance

Any mechanisms for quality assurance at a local level are likely to refer to the
following.

Service and performance targets, including estimated activity levels

and case mix, waiting and referral-to-treatment times (ensuring that
patients and carers do not experience unnecessary delays), complaints
procedures.
Clinical governance arrangements, including incident reporting.

19
 Clinical quality criteria: appropriateness of referral, consenting
procedures, clinical protocols.
Audit arrangements: frequency of reporting, reporting route and
format, and dissemination mechanisms; this should include auditing the
proportion of eligible patients requiring cardiac rehabilitation who are
provided with care, and monitoring of patient outcomes and
complications. See audit criteria for NICE clinical guideline CG48 on
MI: secondary prevention, which includes recommendations to link with
the national audit of cardiac rehabilitation.
Health, safety and security: infection control, waste management,
confidentiality procedures, legislative requirements.
Equipment: testing and calibration of exercise and monitoring
equipment.
Accreditation requirements: for some or all elements of the service,
the premises and/or staff.
Patient satisfaction: patient and carer perspective and perception of
service provision, complaints.
Patient outcomes: reduced risk of further cardiac problems, improved
quality of life, reduction in hospital admissions, improved return to work
rates, reduced blood pressure and cholesterol levels, improved patient
knowledge and psychosocial well-being and reporting these outcomes
to the National audit of cardiac rehabilitation.
Staff competencies: individual and team baseline requirements,
monitoring and performance. See Implementation advice for NICE
clinical guideline CG48 on MI: secondary prevention for
recommendations on assessing training needs.
Information requirements, including both patient-specific information
(NHS number, referring GP, provision of high-quality information to
patients/carers) and service-specific information (referral-to-treatment
times, workload trends, number of complaints).
The process for reviewing the service with stakeholders, including
decisions on changes necessary to improve or to decommission the
service.
Achieving targets associated with equalities legislation.

Further information
General information on quality and corporate assurance can be obtained
from the following sources:

The National Patient Safety Agency (NPSA) oversees the

implementation of a system to report and learn from adverse events
and near misses occurring in the NHS. The publication Seven steps to
patient safety provides an overview of patient safety and gives updates

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 on the tools that the NPSA is developing to support patient safety
across the health service.
NHS Alliance online resources. NHS Alliance is the representational
organisation of primary care and primary care trusts, and provides
them with an opportunity to network and exchange best practice. The
alliance supports its members with an open-access helpline, in-house
and joint publications and briefings, internal newsletters and a website.
The DH commissioning framework provides guidance on the
commissioning process in the context of the NHS reform agenda.
NHS Institute for Innovation and Improvement support for
commissioners, includes Commissioning for Health Improvement
products to accelerate the achievement of world class commissioning;
The Productive Leader programme to enable leadership teams to
reduce waste and variation in personal work processes, and Better
care, better value indicators to help inform planning, to inform views on
the scale of potential efficiency savings in different aspects of care, and
to generate ideas on how to achieve these savings.
10 Steps to your SES: a guide to developing a single equality
scheme. This guidance has been developed to assist NHS
organisations that have a duty, as public authorities, to comply with the
race, disability and gender public sector duties, and in anticipation of
new duties in relation to age, religion and belief, and sexual orientation.

Specific information on quality and corporate assurance for a cardiac

rehabilitation service can be obtained from the following sources:

Better metrics is a pragmatic project that provides clinically relevant

measures of performance to support the development of measurable
local targets and indicators for local quality improvement projects. See
heart disease and stroke metric.
The Quality and outcomes framework (QOF) was designed to deliver
substantial financial rewards for high-quality care. The framework sets
out a range of national standards based on the best available research
evidence.
Skills for health works with employers and other stakeholders to
ensure that those working in the sector are equipped with the right
skills to support the development and delivery of healthcare services.
See details of the coronary heart disease competency framework.
A skills-based operational framework for practitioners with a special
interest in cardiology from the Heart Improvement Programme sets out
a national standard for training courses for practitioners with a special
interest in cardiology and is endorsed by many national organisations
including the Royal College of General Practitioners.

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Topic-specific Advisory Group
A topic-specific advisory group was established to review and advise on the
content of the commissioning guide. This group met once, with additional
interaction taking place via email.

Jenny Cadman
Cardiac Rehabilitation Manager and Senior Nurse in Cardiology, Luton and
Dunstable Hospital NHS Foundation Trust

Dr Hasnain Dalal
General Practitioner, Truro, Cornwall

Prof Patrick Doherty

Professor of Rehabilitation, Faculty of Health and Life Sciences, St John
University, York and President of the British Association for Cardiac
Rehabilitation

Judith Herbert
Vascular Programme Policy Officer, Department of Health (London)

Ben Knight
Service Development Team Manager, Leicestershire, Northamptonshire and
Rutland Cardiac Network

Margaret Leid
Director, Cheshire and Merseyside Cardiac Network

Prof Bob Lewin

Director, British Heart Foundation, Care and Education Research Group

Dr Anita Roy
Consultant in Public Health, Wakefield District PCT

Dr Matthew Thalanany
Associate Director of Public Health Medicine, South West Essex PCT

Helen Williams
Pharmacy Team Leader for Cardiac Services, Kings College Hospital NHS
Foundation Trust

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