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Cardiac rehabilitation service

Commissioning guide

Implementing NICE guidance

March 2008

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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 people’s 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 individual’s 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’

• The ‘

supports the development of cardiac networks and ensures the spread of service improvements.

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.

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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 80–90% 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 70–80% of people with heart failure would be suitable for cardiac rehabilitation, and the take-up of those referred would be around 60–80%

• 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

Diagnosis/procedure

Percentage of population

discharged alive in 2006/07

Percentage of

discharged population suitable for

cardiac rehabilitation

referral

Percentage (optimal) of population suitable for referral who

take up cardiac

rehabilitation

Combination of referral

and optimal take-up

(percent) – that is,

attendance

Percentage (optimal) of discharged population

who take up cardiac

rehabilitation based on

2006/7 data

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Therefore the population benchmark for a cardiac rehabilitation service is estimated to be 0.20%.

Use the cardiac rehabilitation service commissioning and benchmarking tool

References

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.

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: 372–8.

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: 1–166.

Myocardial infarction 0.12 85 80 68 0.082

Percutaneous coronary intervention

0.02 100 85 85 0.017

Coronary artery bypass graft 0.04 100 85 85 0.034

Heart failure 0.07 75 70 53 0.037

Implant of a cardiac defibrillator 0.004 100 85

85 0.0034

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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.

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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 patient’s and carer’s 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.

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• 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