Balance of Care Inquiry Scottish Campaign for Cardiac Rehabilitation

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1 It may be surgery that brings you to the foothills of the Alps, but it's the Cardiac Rehabilitation Programme that gets you over them.' Heart patient, Ayrshire and Arran Introduction The was launched in March 2008 by an alliance of patient organisations, health professionals and heart charities creating one powerful voice to champion the cause of cardiac rehabilitation. British Heart Foundation (BHF) Scotland and Chest, Heart & Stroke Scotland (CHSS) are the organisations leading the campaign. Rehabilitation is an immensely important treatment for heart patients: it reduces premature mortality and hospital readmissions and improves quality of life. It is also very inexpensive compared to other treatments and interventions: cardiac rehabilitation only costs around 600 per patient, compared to 8,000 for a bypass operation. i Encouraging participation in cardiac rehabilitation makes financial sense and could go a long way to reducing the financial burdens on the NHS. I'm firmly convinced that the Cardiac Rehabilitation programme does prevent recurring cardiac problems in most cases and is an excellent preventative measure, which must save the NHS a considerable amount of money!' Heart patient, Grampian Great progress has been made in Scotland to ensure that heart attack and cardiac bypass patients get cardiac rehabilitation. Provisional figures from ISD Scotland provided to the Campaign suggest that up to 60% of these patients take part in a cardiac rehabilitation programme, which is a relatively high rate but still leaves room for improvement; by targeting services at the groups who are often excluded, such as people from ethnic minorities, for example, or those who are living in deprivation and by providing innovative rehabilitation delivery to meet the needs of the wider population. For other heart patients, particularly those with long-term conditions, the situation is not so good. Only 3% of angina patients in Scotland receive cardiac rehabilitation and less than 1% of heart failure patients receive it. ii Urgent action is needed in these areas to ensure that these patients get the benefits that high quality cardiac rehabilitation can offer, to prevent deaths, improve quality of life and prevent future cardiac events. The importance of cardiac rehabilitation as a means of cutting premature mortality was recognised in SIGN 57 published in The British Association for Cardiac Rehabilitation (BACR) Standards and Core Components for Cardiac Rehabilitation (2007) sets out in detail what high quality cardiac rehabilitation should look like.

2 More than 190,000 people in Scotland currently receive hospital treatment for heart disease iii and, as premature death rates continue to fall, more and more people than ever will be living with heart disease. If our health service is to cope with these increasing numbers it is crucial that cardiac rehabilitation services are able to meet demand, to spare valuable NHS resources and act in the interests of the increasing numbers of people living with heart disease. This is one of those rare win-win situations, and we warmly welcome the Committee s interest in it. Key questions What are patients experiences of rehabilitation services? How will the framework change services to patients? Patients who have taken part in cardiac rehabilitation tend to have a very positive experience. Qualitative research commissioned in 2007 iv and featuring interviews with one hundred patients across the UK found that:...cardiac rehabilitation played a key role in restoring their physical, psychological, social and vocational wellbeing. Many patients expressed a noticeable benefit from being in the same boat as others living with heart disease. They gained a mental boost from shared cardiac rehabilitation, even though the majority never met outside the sessions. v These factors are especially important for the successful recuperation of heart patients- being anxious or depressed is associated with people being three to four times more likely to die from their condition. vi Cardiac rehabilitation promotes independence and encourages self-management, restoring confidence and increasing compliance with lifestyle changes. 'I would, without hesitation claim that [cardiac rehab] turns your life around after a major heart event and the camaraderie dispels any depression and gives you the zest for life.' Heart patient, Greater Glasgow and Clyde The framework recognises the challenges of accessing rehabilitation and among heart patients, it is well recognised that people who do not participate in a programme often have greater degrees of functional impairment and are the ones most in need of and most likely to benefit from rehabilitation. vii Other reasons for low access to cardiac rehabilitation include; transport and lack of tailoring in class provision; women report the differences in physical functioning as compared to men and privacy issues. The endorsement of health professionals throughout the patient pathway is also cited as an important factor in increasing adherence to cardiac rehab. viii It is crucial that service provision is as flexible as possible, to ensure that all patients, across all heart conditions, and especially those in currently

3 underrepresented groups, such as women, people from ethnic minorities, or those who are living in deprivation, are able to take advantages of the benefits that rehabilitation has to offer. How will the framework change the role of allied health professionals in delivering rehabilitation services? Are current community facilities adequate? To what extent are they able to meet new demands that the framework places on them? The Scottish Campaign knows anecdotally, and through our work with heart patients, health professionals working in cardiac rehabilitation and groups like the Cardiac Rehabilitation Interest Group Scotland (CRIGS), that rehabilitation services are rarely as flexible as they need to be or have the capacity that is required by the increasing numbers of those living with heart conditions. Accurate data is currently unavailable due to the current lack of a Scottish Audit on rehabilitation, although we note that plans are progressing to remedy the situation; the Scottish Campaign would be delighted to work with NHS Scotland in this area. There are already at least 190,000 people in Scotland with heart disease and, if the death rate continues to fall combined with our ageing population, we know that that this number is set to rise. We also know from the Scottish Campaign figures that a relatively low proportion of these people have taken part in cardiac rehabilitation. The emphasis on local provision in the framework is welcomed by the campaign, but we also recognise that an increase in resource is required in addition of change of location to fully meet demand. Successful cardiac rehabilitation programmes are currently those delivered by a multi-disciplinary team. It is crucial, therefore that adequate training and support is in place, cardiac rehabilitation can flourish in a variety of community based settings. The Scottish Campaign also recommends innovative delivery to improve access to rehabilitation and this can be achieved through supporting all professionals to try out new ideas and explore new initiatives to benefit heart patients. What changes need to be made to workforce planning and social services to allow the framework to be implemented? How far are NHS boards, local authorities and associated bodies able to fulfil their roles under the framework? What changes in financing will be required as a result of shifts in the balance of care, particularly between acute and primary care/community health budgets? What barriers to the successful implementation of the framework exist? How can these be overcome? The generic framework for rehabilitation covers many areas relevant to the on paper and we would be keen

4 to see these recommendations implemented to benefit heart patients as soon as possible. As we have highlighted, while the numbers of heart attack and cardiac bypass patients in Scotland getting access to cardiac rehabilitation leave much to be desired, the numbers of people with other heart conditions getting it is shockingly low. A primary benefit of cardiac rehabilitation, cited by patients, is the opportunity to spend time with others in the same boat and therefore we would like to highlight the importance of continuing to address the needs of specific conditions within a generic framework of provision. The shift in emphasis to community provision is likely to be most beneficial to those heart patients with currently very low access opportunities to cardiac rehab; angina and heart failure patients. People who have had heart surgery or heart attacks are easier to access (i.e. their treatment takes part in a hospital) and the nature of that event and its severity can inevitably make patients more willing to taking part in a programme that addresses lifestyle change. For patients who perceive that they haven t had such a major event, and/or who have not been hospitalised, this rationale may be much less clear cut. Many people with angina, for example, will only have contact with health professionals through primary care, which can make targeting services at them more of a challenge. In sheer financial terms, there is a clear imperative for getting patients with angina to take part in cardiac rehabilitation and prevent them having a more severe cardiac event which will require expensive hospital treatment. For heart failure patients there is an additional factor for consideration; anecdotally, we understand that there is a degree of trepidation amongst health professionals about providing rehabilitation in heart failure. There is a perception that rehab may be higher risk among this group, despite a growing body of evidence indicating improved prognosis as well as significantly improved quality of life as a result of taking part in a cardiac rehabilitation programme. ix The provision of rehab in heart failure is therefore likely to involve a commitment to training and support for staff to increase their confidence in delivering this very beneficial service locally. BHF Scotland and Chest, Heart & Stroke Scotland as the lead organisations in the are keen to explore ways that we can work with health professionals to promote understanding and awareness of these important issues. We would welcome the opportunity to work with the Government and NHS Scotland on the rehabilitation agenda. Ben McKendrick BHF Scotland 9 July 2008 i Extrapolated by National Audit for Cardiac Rehabilitation from Health Technology Assessment 2004; Vol. 8: No. 41 October Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under-represented groups. AD Beswick, K Rees, I Griebsch, FC Taylor, M Burke, RR West, J Victory, J Brown, RS Taylor and S Ebrahim ii Figures provided to by ISD Scotland iii ISD Scotland

5 iv BHF Research project to explore the practical, social and emotional implications of living with Coronary Heart Disease, available from BHF v Ibid vi SIGN 57, 2002 vii Harlan W.R., Sandler S.A., Lee K.L., Lam L.C. & Mark D.B. (1995) Importance of baseline functional and socioeconomic factors for participation in cardiac rehabilitation. American Journal of Cardiology, 76, viii Beswick A et al Improving uptake and adherence in cardiac rehabilitation: literature review (2005) Journal of Advnaced Nursing 49(5), at pgs ix Refers to Exercise training meta-analysis of trials in patients with chronic heart failure, BMJ 2004 jan 24, Piepoli et al