Cardiac rehabilitation provision in England: a national survey (A Thesis submitted for the degree of Master of Philosophy)

Abstract

Introduction: The context of the known benefits of cardiac rehabilitation, coupled with the requirements of the National Service Framework (NSF) for Coronary Heart Disease (Department of Health, 2000) and the adoption of the Scottish Intercollegiate Guideline Network guideline (SIGN, 2002) should give clear direction to all cardiac rehabilitation (CR) services. Despite the publication of these guidelines, little evidence of implementation has been reported and variation in service models and delivery are shown to exist (Bethell et al, 2001, 2004; Child, 2004). Objective: To examine CR programmes in England in detail to investigate trends in current provision. Where deficiencies from the national requirements and guidelines are established, recommendations for improvements in delivery will be made. Methods: Three groups of services were targeted: a random selection from each of England’s 28 strategic health authorities, and all CR services within two Cardiac Networks, one rural and one urban. The total sample was representative of 16% of the 332 identified CR services in England. Factual information sought through postal questionnaires included: structure and organisation, funding and budget, staffing, patients included, and implementation of the guidelines. Results: Provision of CR in England remains variable. Only 26% of services meet national standards for staffing levels with less than half holding their own budget. The NSF priority patients: post myocardial infarction (MI) (97%) and revascularisation (78%) are most likely to be included, whereas other patient groups are not routinely gaining access: transplant (44%), implantable defibrillator (ICD) (32%), heart failure (18%) and angina (14%). In comparison to post MI patients, statistical differences were shown to exist (p<0.05) in access to patients who had heart failure, an ICD inserted or angina. Services remain largely hospital-based (49%) with some evidence of integration between primary and secondary care (37%). Overall achievement of the recommended guidelines is poor. Significant difference existed between the three groups of services in terms of recommendations achieved for NSF (F(2,51)=34.9;p< 0.05) and SIGN (F(2,51)=14.2;p<0.05). The overall relationship between NSF and SIGN achievement was found to be statistically significant (r=0.65). Conclusion: Limited staffing and resources has contributed to only 60% of the NSF recommendations and 62% of the national adopted guidelines being achieved, resulting in the inability to make management planning decisions locally and lack of quality of care. Recommendations for improvement have been made.