Cardiac rehabilitation services

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg40

5 Service specification for cardiac rehabilitation

Commissioners should collaborate with clinicians, local stakeholders, and service users when determining what is needed from services for people attending cardiac rehabilitation in order to meet local needs. The care pathway should be person/patient-centred and integrated with other elements of care for people/patients with cardiovascular disease and other long-term conditions.

Commissioners may wish to consider commissioning cardiac rehabilitation in a number of different ways, and mixed models of provision are likely to be appropriate within a local area. Commissioners may wish to take action to stimulate the local market if there are identified shortages of providers at any point in the pathway, and should note that any qualified providers may include health, local authority, other statutory partners, private or third sectors.

Commissioners should ensure that providers implement the recommendations stipulated in NICE guidance and that providers are taking steps to achieve the standards set out in NICE quality standard for chronic heart failure.

Commissioners should ensure the services they commission represent value for money and offer the best possible outcomes for their service users. Commissioners should refer to the NICE quality standards for chronic heart failure when commissioning services and should include quality statements and measures within the service specification element of the standard contract where appropriate. If poor performance is identified, commissioners can discuss the level of performance with their providers and address any issues and concerns before introducing more formal contractual remedies.

Commissioners may choose to use quality standards to ensure that high-quality care is being commissioned through the contracting process, to establish key performance indicators as part of a tendering process and/or to incentivise provider performance by using the indicators in association with incentive payments such as Commissioning for Quality and Innovation (CQUIN).

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

includes considerations for commissioners when developing a contract specification for cardiac rehabilitation.

Table 10 Considerations for contract specification for cardiac rehabilitation

Heading	Section	To be described in service specification
Purpose	Policy context	Evidence base, for example NICE guidance and Quality standards, NHS evidence National policy drivers for cardiac rehabilitation including the National Service Framework for coronary heart disease
	Local strategic context	Local commissioning drivers (for example. reducing hospital admissions and length of stay, QIPP, CQUIN). Results of joint strategic needs assessment (JSNA).
	Aims and objectives of service	The expected outcomes of the service(s).
Service scope	Define service user groups	Demographic profile of the local population (age, gender, ethnicity, socio-economic status). Conditions to be targeted by local cardiac rehabilitation programmes. Local recorded and expected prevalence of conditions to be targeted by local cardiac rehabilitation programmes. Estimated prevalence of comorbidities (for example, hypertension, stroke, chronic obstructive pulmonary disease, depression). Evidence of inequalities in outcomes between specific groups. Number of wholly attributable and partially attributable MI and chronic heart failure-related hospital admissions, bed days and readmissions.
	Exclusion criteria	Define exclusion criteria for service(s) in accordance with NICE guidance and locally determined criteria.
	Geographical population	Proportion of people living in urban and/or rural areas. Areas of higher-than-average need – for example, areas of deprivation and areas with a high population of older people. Population coverage required or geographical boundaries.
	Service description / care package	Mapping existing cardiac rehabilitation services. Commissioning of core service components. Interface with other local services including weight management services, smoking cessation, leisure services.
Service delivery	Location	Service location(s), defining accessibility requirements and discreet location(s). Integration with other services for people with cardiovascular disease. Home-based, locality based services and centrally based services.
	Days/hours	Expected hours of operation, including days, evenings and weekends where appropriate. Expected number of patients, taking into account potential increased flow through the system over defined periods
	Referral processes	Referral criteria and processes. Management of 'unable to attend' (UTAs) and 'did not attends' (DNAs). Processes to maximise referral and uptake.
	Response times	This should be needs-based and outcomes-based. Setting specific times – for example, response to referral, waiting times for assessment and to commence programme.
	Care pathways	Agreed clinical protocols or guidelines to support decision-making in the patient pathway. Use of third sector – for example, leisure facilities. Care coordination.
	Discharge processes	Process for discharge from cardiac rehabilitation, including long-term disease management.
	Staffing	Profile of existing health and social care workforce. Staffing levels to be funded: minimum band or levels of level of experience and competency and expected skill mix.
	Information sharing	Define information sharing, confidentiality and audit requirements, including IT support and infrastructure. Raising awareness of cardiac rehabilitation. Do patients and health and social care professionals know how to access services?
Quality assurance and clinical governance	Patient and public involvement	Processes to understand patient experience of cardiac rehabilitation in order to develop and monitor services. Expectations of how patient opinion, preference and experience will be used to inform service delivery for example, focus groups, representation on working groups, and surveys. Monitoring of complaints and complements and how they are used to inform service.
	Quality indicators	Use NICE quality standards to define high-quality care. Patient satisfaction surveys on services and access to treatment. Define outcomes and (proxy) measures, including uptake, adherence and completion rates
	Performance monitoring	Impact of service(s) on admissions to 'Accident and Emergency' departments, inpatient hospital care and length of stay in hospital.
	Equality	Measures to ensure equality of access to services, taking into account the risks of unintentional discrimination against groups who are often under-represented, such as people who do not speak English as a first language. Consider equity of access for people living within residential homes and those who are housebound; or people within prisons.
	Staff training and competency	Training and competencies on recruitment and for ongoing development. Skill mix and competencies required across the care pathway, including competencies in: assessment, behavioural change and motivational interview, personalised care planning, provision of exercise and identifying palliative care needs. See Skills for Health for examples. See BACR Exercise Professionals Group (EPG) Position Statement 2010: Essential competences and minimum qualifications required to lead the exercise component in early cardiac rehabilitation Staff development – appraisal and personal development plans, and mandatory training.
	Audit	Specify expectations for regular clinical audit, including reporting arrangements, which may include the National Audit of Cardiac Rehabilitation which has been adapted to capture key rehabilitation processes and clinical outcomes. See audit support and electronic audit tool for NICE clinical guideline CG108 and audit support for CG48. See also audit criteria for NICE public health guidance PH1 on brief interventions and referral for smoking cessation; NICE audit support for smoking cessation services; and NICE audit support for CG91 on depression with a chronic physical health problem.
	Staff and patient safety	Procedures for risk assessment. Formal procedures for incident reporting and monitoring. Address any safeguarding concerns and promote the welfare of vulnerable adults.
Activity plan		Long-term impact of increased access to improved assessment and diagnosis on referrals to other services, hospital admissions and bed days. Planned service development setting out any productivity improvements. Capture of information relating to outpatient cardiac rehabilitation activity using treatment function code 327 Cardiac Rehabilitation: Rehabilitation service for patients with or recovering from heart related conditions such as heart attacks or from procedures such as coronary artery bypass surgery to ensure that they achieve their full potential in terms of physical and psychological health.
Cost	Value for money	Likely cost of new or additional services. Anticipated set-up costs. Anticipated savings from reduction in admissions. How will pricing be set? Potential for better value for money. Are patients receiving most appropriate services? Cost of facilities, for example venue hire Cost of staff travel to services and patients' homes. QIPP. See the commissioning and benchmarking tool for further information.