Transcript The 7th York Cardiac Care Conference Why does cardiac

The 7th York Cardiac Care
Conference
Why 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
Historical perspective
30 years on……
Action Heart Income (£000s)
Cardiac Rehabilitation
100
225
225
35
Donations and
Fundraising
Other Clinical Services
140
Health Club Income
Source of Action Heart Income (%)
Cardiac Rehabilitation
20%
7%
45%
28%
Donations and
Fundraising
Other Clinical Services
Health Club Income
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, expatients 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)
Important part of success
Patients, Carers and Volunteers
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
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
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
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
Percentages of patients reported
referred to ‘rehabilitation’ in
MINAP, J. Birkhead June 2003
Cardiologist
Other
Physician
Yes
No
Unknown
STEMI
76
12
12
Non
STEMI
STEMI
69
18
13
70
14
16
Non
STEMI
64
20
16
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
Straw poll survey of Networks
• CR reviews informing
work plans in majority
of 18:32
• 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
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
BHF/NOF Rehabilitation 2004
• Areas in 22:32 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
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
Explaining Mortality Reduction 19802000
48% of CVD mortality reduction since 1980 has come from
reductions in smoking.
32% of reduction comes from secondary prevention and
other primary prevention.
Smoking reduced 48%
Blood pressure
lowered
Fat
reduced
Reduced
deprivation
9.5%
9.5%
3%
Increased risk of
obesity/physical
inactivity
-12.%
Circa 60%
from risk
factor
modification
Informed assessment from
analysis of english language
literature in England, US,and
Europe
Circa 40%
from
treatment
11%
8%
5%
3%
Secondary
prevention
Thrombolysis &
other AMI
Surgery or drugs
for angina
Treatment for
hypertension
13% Other
Primary sources Belgin et al [2004], Capewell et al [1999] , McPherson [2001]
PCI without comprehensive risk
factor modification is a sub-optimal
therapeutic strategy
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 2004;109:1371-1378
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
Successful Health Alliance
Recognised by Department of Health 1993
Beacon Award 2000
Walking route location
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.
Neighbourhood Walk
Information
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
Champion Patient
Change as an equation
F(D+V+S+M)>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
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
“Be the change you want to see”
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