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The 7th York Cardiac Care Conference Why does cardiac rehabilitation struggle for funding

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Clinical Director Black Country Cardiac Network. President BACR 1997-9, Member NSF External Reference Group ... V: NSF, SIGN, AACVPR, JBS2, ACPICR, BACR IV, ACSM, NICE ... – PowerPoint PPT presentation

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Title: The 7th York Cardiac Care Conference Why does cardiac rehabilitation struggle for funding


1
The 7th York Cardiac Care ConferenceWhy does
cardiac rehabilitation struggle for funding?
  • Dr Jane Flint BSc MD FRCP
  • Medical Director Action Heart Dudley
  • Clinical Director Black Country Cardiac Network
  • President BACR 1997-9, Member NSF External
    Reference Group
  • British Cardiovascular Society Council and
    British Heart Foundation Trustee

2
Historical perspective
  • 30 years on

3
100
225
225
35
140
4
20
7
45
28
5
Challenges for Cardiac Rehabilitation
  • Increasing participation (daytime sessions
    preferred by elderly, women, housewives,
    husbands, non-car owners)
  • Increasing compliance (employed often require
    evenings, shiftworkers need day/eve options)
  • Increasing capacity (additional income, health
    club, ex-patients and partners, NHS staff and
    partners, exercise referral scheme for high risk
    primary preventive, other medical conditions)
  • Increasing choice (to suit lifestyle eg
    grandparents need to avoid the school run)

6
Important part of success
  • Patients, Carers and Volunteers

7
Patient and Carer Involvement
  • Support for fellow patients and carers (and
    within Network Patient Carer Partnership)
  • Volunteer staff ( equiv. value 40,000 p.a.)
  • Feedback and consultation on services and
    pathways (QPDT, LIT Network too)
  • NICE group

8
Finance
  • Capital bids initially
  • New Opportunities Fund/BHF Partnership to deliver
    grant programmes for community based cardiac
    rehabilitation and heart failure networks (14
    million)
  • - focussed projects with targets
  • - complement existing provision
  • - further access to sustainable development
  • - partnership/continued funding

9
Finance 2
  • Patients Choice programme suspect variable
    level of investment
  • Recurring 100million 70 CABG/PCI
  • NB to fund pathway including cardiac
    rehabilitation (also cath lab, PCAs etc)
  • All PCTs have extra 9 funding
  • Major capital developments should include costs
    of entire patient pathway including primary and
    secondary care ( CR and SP)
  • Heart Team, May 2003

10
So why the struggle?
  • Limited ring-fenced funding/access
  • Lack of appropriate outcome target, despite
    service standards
  • Lack of audit information until NACR
  • Lack of appointed leadership at all levels
    national, network, LIT, QPDT
  • Lack of commitment/ power to change
  • Compelling, competing priorities
  • ?PbR (not alone)
  • Change to PCT responsibility, but also LITs and
    Networks which should be planning/ commissioning
    services

11
Percentages of patients reported referred to
rehabilitation in MINAP, J. Birkhead June 2003
12
Cardiac Rehabilitation and Cardiac Networks
  • Ideal service for Network planning
  • Work plans 2006/7 only 18 out of 32 included CR
  • 2007/8 23 out of 32 have
    CR in draft plans, but competing priorities for
    funding with 18 week target, and Network
    reorganisation has carried forward plans for CR
    reviews

13
Straw poll survey of Networks
  • CR reviews informing work plans in majority of
    1832
  • Cross-Network protocols, strategy business case
    for leverage
  • Work slowed with PCT/ SHA/Network project manager
    change
  • Anxiety about PbR tariff being used to stall
    progress

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

15
BHF/NOF Rehabilitation 2004
  • Areas in 2232 Cardiac Networks were successful
    in their rehabilitation bids likely to underpin
    the work plans now volunteered.
  • Concept of critical level of funding for
    rehabilitation community development

16
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17
1.2.2 The cardiac rehabilitation team will
include a cardiologist
  • British Cardiovascular (previously Cardiac)
    Society recommendation - District Working Party
    1994 Interface Report 1997 Fifth Joint Report
    2002

18
Explaining Mortality Reduction 1980-2000
48 of CVD mortality reduction since 1980 has
come from reductions in smoking. 32 of
reduction comes from secondary prevention and
other primary prevention.
Informed assessment from analysis of english
language literature in England, US,and Europe
Circa 60 from risk factor modification
Circa 40 from treatment
Smoking reduced 48
Secondary prevention
Blood pressure lowered 9.5
11
Thrombolysis other AMI
Fat reduced 9.5
8
Surgery or drugs for angina
5
Reduced deprivation 3
Treatment for hypertension
Increased risk of obesity/physical
inactivity -12.
3
Other
13
Primary sources Belgin et al 2004, Capewell et
al 1999 , McPherson 2001
19
PCI without comprehensive risk factor
modification is a sub-optimal therapeutic strategy
20
PCI compared with Exercise Training in Patients
with stable CAD
  • Compared with PCI, 12-month programme of regular
    physical exercise in selected patients with
    stable CAD resulted in superior event-free
    survival and exercise capacity at lower costs,
    notably owing to reduced rehospitalizations and
    repeat revascularisations.
  • Hambrecht,R et al. Circulation
    20041091371-1378

21
NACR 2005-6 cost of CR 413
  • Modest compared with CCU stay, PCI or CABG
  • Cost-effective
  • Underpins expert patient development/further
    empowerment of heart patients
  • BUT
  • Little revenue for private sector
  • No marketplace advantage for service
    true/false?
  • Major lifestyle improvement will SAVE resource

22
Successful Health Alliance
  • Recognised by Department of Health 1993
  • Beacon Award 2000

23
Walking route location
24
                                                
                                                  
                                                  
        
Thanks to 4th, 5th and 3rd year Medical
students On pilot David Cole Of Directorate Of
the Urban Environment Graphic Design studio Russ
Tipson, Director of Action Heart Barbara
White, Dudley Clinical Education Centre
Manager.
25
Neighbourhood Walk Information
26
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27
Recommendations
  • Cardiac rehabilitation should be firmly
    established in partnerships with the local
    community to achieve targets
  • PPI provides a major empowering contribution
  • BHF/ NOF funding has made the greatest
    contribution since the NSF for CHD extend
    innovation
  • Cardiac Networks should ALL have CR work plans
    encouraged by HIP, and led by a local
    Cardiologist with commitment to see CR
    represented in all relevant fora
  • Patient Choice revascularisation funding stream
    should include accountability for the CR pathway
    in re-alignment of resources with changing work
    patterns

28
Champion Patient
29
Change as an equationF ( D V S M ) gt R
  • D Dissatisfaction with the current situation
  • V Vision of the future in some form
  • S An idea of what the next steps might be
  • M Mindset that it is right and possible to do
  • R Reluctance or resistance to change

30
Cardiac Rehabilitation
  • D many patients still cannot access CR
  • V NSF, SIGN, AACVPR, JBS2, ACPICR, BACR IV,
    ACSM, NICE
  • S protocol/ICP driven management and audit NACR
  • M Fifth report HCC NSF review BCS Peer Review
  • R neglect reducing, BUT workforce constraints
    and poor share of resource

31
Be the change you want to see

32
Acknowledgements
  • Russell Tipson, Team and Patients, Action Heart,
    Dudley
  • Black Country Cardiac Network Rehabilitation
    sub-group to Clinical Governance Group
  • Linda Binder, NHS Heart Improvement Programme
  • David Geldard, President Heart Care Partnership
    UK and Trustees
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