Cardiac Rehabilitation (Clinical Standards)
The next item of business is a members’ business debate on motion S4M-04623, in the name of Helen Eadie, on clinical standards for cardiac rehabilitation. This debate will be concluded without any question being put.
Motion debated,
That the Parliament welcomes the publication of the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012; acknowledges that the aim of the standards is to ensure that cardiac rehabilitation programmes are clinically and cost effective and achieve sustainable health outcomes for patients; understands that cardiac rehabilitation is one of the most effective interventions in the management of heart disease through the prevention of re-admissions to hospital and unnecessary appointments in primary care, the education of patients and their families on where to seek advice and information and its focus on the self-management of cardiac conditions; considers that the BACPR standards and their seven core components are at the forefront of acknowledging the achievements of cardiac rehabilitation programmes in Scotland and can be used to encourage continuous improvement to patient outcomes and experience through this vital intervention in Fife and across the country, but is concerned that, despite improvements in the provision of cardiac rehabilitation for patients with acute conditions across Scotland, its provision for patients with heart failure and for angina remains very low.
12:34
I start by thanking all my colleagues in the Scottish Parliament and you, Presiding Officer, for enabling me to bring to Parliament this afternoon a debate on a topic about which I am very enthusiastic. The subject is very important, so I offer the motion to colleagues for their support.
Modern cardiac rehabilitation is menu based and patient centred, and it provides a pathway from diagnosis to long-term management while meeting patients’ physical, psychological and social needs. It reduces all-cause mortality by up to 26 per cent and cardiac mortality by up to 36 per cent, while reducing unplanned hospital admissions by up to 56 per cent.
As members may be aware, I convene the cross-party group on heart disease and stroke. I have heard at first hand from patients and health professionals how popular cardiac rehabilitation is and how important rehab can be in aiding recovery from heart conditions.
The British Association for Cardiovascular Prevention and Rehabilitation—BACPR—presented on its standards at our last meeting in December, and made a compelling case for the extension of cardiac rehabilitation to every heart patient who needs it.
BACPR, the British Heart Foundation Scotland and Chest, Heart and Stroke Scotland want assessment for cardiac rehab to be mandatory for every heart patient. That would cut hospital readmissions, as well as unnecessary primary care appointments. Cardiac rehab is highly cost effective, especially when compared to surgical interventions.
I have been fortunate enough to visit in my constituency a cardiac rehab class that is part of BHF’s hearty lives programme. That project allowed the Fife cardiac rehab service to increase capacity by offering new programmes in different settings, including a community evening class. As a result, referrals doubled. That programme has been mainstreamed, and I hope that other national health service area boards may consider what lessons can be learned from that approach.
The NHS Quality Improvement Scotland clinical standards for heart disease from 2010 mandated an assessment for cardiac rehabilitation for all patients with the most common heart conditions. The Government’s “Better Heart Disease and Stroke Care Action Plan” of 2009 also indicated that NHS boards should regard cardiac rehab as a priority.
Referrals for rehab have improved since those documents were published, but not quickly enough—especially not for long-term heart conditions such as heart failure and angina. That is possibly because much of the published evidence for cardiac rehab—at least in terms of reductions in premature mortality—focuses on the benefits for acute patients, such as heart attack and bypass patients.
However, there is a growing body of evidence that shows that cardiac rehab for heart failure patients has significant benefits in terms of reducing unnecessary hospital readmissions and is, therefore, a highly cost-effective treatment for such patients.
A small study from Australia that has been discussed at the cross-party group compared hospitalisation rates for two groups of heart failure patients: one that had access to rehab once a week and one that had no such access. The group that received cardiac rehabilitation spent, on average, 9.36 days a year fewer in hospital than those who did not receive it. The authors calculated that for every 1 Australian dollar spent on rehab, 11.50 Australian dollars were saved through reduced rehospitalisation costs. I understand that the cardiac rehab team in NHS Ayrshire and Arran is looking to replicate that study using data from that area.
It is estimated that 70,000 people in Scotland are living with heart failure and figures from ISD Scotland suggest that only 3 per cent of those patients are being referred for rehab. How much money could be saved if, as a result of referrals to rehab for heart failure patients, the NHS were to save £11 for every £1 that it spent?
I urge the minister to consider what more the Government can do to improve provision of those crucial services, especially for long-term cardiac conditions such as heart failure. In particular, I urge him to consider what steps are needed to develop a sustainable audit, by NHS board area and by specific heart condition, of the provision of rehab services, and to consider what additional policies should be employed to drive assessments for cardiac rehab across the country.
The briefing that has been provided by the Scottish campaign for cardiac rehab suggests that the Government should consider a health improvement, efficiency and governance, access and treatment—HEAT—target for referrals to rehab for all patients. I urge the minister to take that on board.
I hope that politicians of all parties, the main charities that have campaigned for improvements in cardiac rehabilitation services for years—the British Heart Foundation Scotland and Chest, Heart and Stroke Scotland, and so on—NHS boards and health professionals on the ground can work together in the year ahead to ensure that every heart patient is referred for cardiac rehabilitation as a matter of course.
12:40
I thank Helen Eadie for securing this debate on an extremely important issue.
As vice-convener of the cross-party group on heart disease and stroke, I too have had the privilege, on many occasions, of hearing about the substantial benefits that arise from provision of cardiac rehabilitation for all heart patients. Following open heart surgery in 2006, I also have personal experience of how effective cardiac rehab can be.
Last year, the group heard a presentation from the British Association for Cardiovascular Prevention and Rehabilitation on the new standards on which Helen Eadie’s motion focuses. Those standards include the goal of
“Ensuring referral of all eligible patients by cardiologists and/or specialist cardiovascular health care physicians to a prevention and rehabilitation programme as a standard (not optional) policy that is held in the same regard as the prescribing of cardioprotective medications.”
That is a worthy aspiration towards which we should all be working.
The evidence base for the effectiveness of cardiac rehab is overwhelming, as Helen Eadie said. It is highly cost effective—especially compared with surgical interventions for cardiac conditions—and it reduces premature mortality and hospital readmissions.
The Scottish intercollegiate guidelines network guidelines of 2002 said that cardiac rehab should be provided for all heart attack and bypass patients, and that all patients with heart failure and stable angina with limiting symptoms should be assessed for it. Those were grade A recommendations, which is the highest category of recommendation. In addition, the Government’s 2009 “Better Heart Disease and Stroke Care Action Plan” reiterated that health boards should recognise the importance of providing rehab to all heart patients.
As a result of that focus, NHS Scotland has over the past few years made good progress in improving provision of cardiac rehab, especially for people with acute heart conditions. The figures show that, nationally, 75 per cent of heart attack patients and 68 per cent of heart bypass patients were referred for cardiac rehab.
However, some health board areas still appear to be underperforming in provision of cardiac rehab. In the NHS Highland area, for example, just over 40 per cent of eligible heart attack patients were referred for cardiac rehab. It is clear that providing such services over a large rural area is a challenge, but that figure shows that there is still some way to go.
As is noted in the motion, there are particular issues to do with the provision of rehab for people with longer-term conditions—especially those with heart failure and angina—right across Scotland. In the NHS Highland area, for example, only 3 per cent of eligible heart failure patients appear to have been referred for rehab in 2011 and, nationally, the proportion of referrals of such patients is no better.
The British Heart Foundation Scotland and Chest, Heart and Stroke Scotland, which have led the campaigning work in this area over the past few years, now say that they believe that the time is right for the Scottish Government to consider what further steps it can take to drive improvements. I agree. Specifically, they feel that ministers should consider whether assessment for cardiac rehab would be a suitable candidate for a new HEAT target, as Helen Eadie said.
I am aware that ministers share the aspiration of the BACPR, the BHFS and CHSS that referral to cardiac rehab should be mandatory for all heart patients, as is the case for many pharmaceutical treatments for cardiac disease. Therefore, I would be interested to hear whether the minister believes that a HEAT target on referrals to cardiac rehab, which the charities are proposing, is something that his officials could examine.
12:44
I congratulate Helen Eadie on securing the debate. She is very committed to the issue and has worked extremely hard over the years, as convener of the cross-party group on heart disease and stroke, to influence the thinking of Parliament and the Government. Today, she brings the Scottish campaign for cardiac rehabilitation to Parliament.
As we heard, the campaign is a collaboration between a number of significant voluntary organisations, including the British Heart Foundation and others that have been mentioned. The aim is to ensure that every suitable heart patient is given access to a rehabilitation programme. That makes sense, because people who undergo rehabilitation get better quicker. Rehabilitation can save and transform lives.
The campaign argues that patients should be offered alternative methods of rehabilitation, which might be based at home, in the community or in hospital, depending on where people are able to take part in programmes, and it argues that it is important to overcome barriers to participation. There might be barriers for people who live in deprived or remote and rural communities, because they might struggle to access services. I was struck by Dave Thompson’s description of inequity in services in his area. The campaign also calls for minimum standards and monitoring, as members have said.
We know that adopting such an approach to cardiac rehabilitation can transform lives and, at the same time, save money, which is no bad thing in a time of austerity. I understand from the campaign briefing that rehabilitation has reduced death from heart disease by more than a third in just over 10 years. That is a considerable achievement.
The campaign points out that rehabilitation can help to prevent the need for much more costly treatment. A heart bypass costs in excess of £5,000 whereas rehab costs less than £2,000. Cardiac rehabilitation has also cut readmissions to hospital by as much as 30 per cent. The figures make for interesting reading. Cardiac rehabilitation is clearly worth doing, whatever measure we use to consider its effects.
I visited a cardiac rehabilitation group in Dumbarton. The participants had nothing but praise for the physiotherapists and nurses who worked with them. There were a couple of grumbles about what the physios made patients do, but by and large everyone realised that they are fortunate to have good access to an excellent rehab service, which is not the case for everyone in Scotland.
When I met that bunch of people, I could not get over how full of life they were. They might all have had heart attacks, but that was not going to stop them. They were very much looking forward, and having great fun as they did so—the group was filled with laughter. I want that quality of cardiac rehabilitation not just for people in Dumbarton but for everyone in Scotland. The Government needs to spread good practice to every health board and every corner of the country.
I congratulate the NHS on what has already been achieved. The action plan is a positive step forward and staff in many areas have embraced it and are working to implement it. That is evident from the 60 per cent fall in the mortality rate for heart disease.
We know that we can do more and that we can accelerate the pace of change. Members of this Parliament do not often all sing from the same hymn sheet, but we are doing so today as we ask the Government to consider a HEAT target, accelerate the pace of change and ensure that monitoring arrangements are in place, so that the aims of the campaign can be met and cardiac rehabilitation services can improve not just in one or two areas but throughout the country. I hope that the minister will be able to tell us that that will happen.
12:49
I congratulate Helen Eadie on bringing this debate to the Parliament. I, too, am a member of the Parliament’s cross-party group on heart disease and stroke.
Members will not often hear me say that I will sing the same tune as Jackie Baillie is singing—whether we are singing from a hymn sheet, a song sheet or whatever. However, Jackie Baillie’s point about preventative spend made good sense.
Helen Eadie mentioned the payback of 11 Australian dollars for every Australian dollar spent on rehabilitation, but the issue is much more important than that. It is about saving lives, enhancing lives and ensuring that, when rehabilitation is given, people can generally lead, more often than not, a normal life. That is the important factor.
I am sure that the Government will not miss the fact that providing the appropriate rehabilitation—whether it is hospital based, community based or domicile based—is cost effective. Domicile-based and community-based rehabilitation is certainly much preferred in our remote and rural areas—I think that Dave Thompson alluded to that.
The percentage of people who receive rehabilitation is far too low. We know that people themselves have a role to play in that. Diet and exercise are important, but structured formal rehabilitation is by far the best way of saving lives.
We need to congratulate all the charities involved. We have heard about the British Heart Foundation Scotland, and Chest, Heart and Stroke Scotland, but many other local charities are trying to assist and provide good guidance and peer support for people with heart conditions. Helen Eadie mentioned the psychological aspect of people and families who are coping with heart conditions. I believe that there is sufficient evidence for the Government to take action on appropriate rehabilitation for our patients in Scotland.
12:51
The distance between Fife and Troon, where, respectively, Helen Eadie and I live, is probably as great as the distance between her and me politically on almost every issue, but in my time in dealing with her I have never thought her to be anything other than enormously big hearted. She is the convener of the cross-party group on heart disease and stroke, and her commitment to the issue has been sustained over a considerable period of time.
I, too, congratulate Helen Eadie on the motion that she has lodged. If more members had heard some of what she had to say and what has been said subsequently, it would have been to their benefit. I hope that, as some of those members may one day benefit from the work and efforts of the cross-party group, the British Heart Foundation and all the other campaigning groups, they will be a little better informed on the issues at hand.
My contribution will be relatively brief, as many points have been made.
We all celebrate advances in healthcare as they are made. The establishment of the national health service after the war essentially brought equality of access to healthcare to everybody in the United Kingdom.
It is interesting that there are two competing challenges for our generation. One is the enormous responsibility that falls on the health service to cope with our emerging lifestyle conditions and an ageing population. The second is how we respond to the extraordinary advances that are being made in healthcare and the consequences and responsibilities that fall from them.
When he was the Secretary of State for Scotland in the mid-1990s, Michael Forsyth—I have to find a way to bring him into debates sometimes—established a material shift in Scottish cardiac care. It may have been Michael Forsyth who did that, but the change enjoyed cross-party support at the time. Even to those who are not his natural admirers, Voldemort has his redeeming qualities. Fifteen years later, we can see a 60 per cent fall in mortality from cardiac incidents.
I suppose that it could be argued from the national health service’s point of view that that is not a financial success. It may have taken the view—not the individuals in it, but from a bottom line—that if people were not there, they would not represent an on-going cost to the national health service. In celebrating that significant reduction in mortality, the responsibility emerges. Thereafter, the question is: what do we do to provide cardiac rehabilitation to those whose lives have been saved?
There is no dispute or concern in relation to the principle or understanding that we need to make advances in cardiac rehabilitation, but a look at the hard facts suggests that whereas the rates of referral to cardiac rehabilitation for those who have had heart bypass operations are considerable—albeit less than the minimum that we might wish for—across health boards in Scotland there is an underperformance on referrals thereafter. There is also a very considerable underperformance, given where we are today and where we need to be, on affording universality of access to cardiac rehabilitation.
In a way, it is tragic if we save lives but leave people with a deteriorating lifestyle thereafter because we do not offer them the support, advice, education and subsequent intervention to ensure that the life that we have saved is a life that remains meaningful. Within a huge institution such as the health service, it is sometimes difficult to ensure that those cross benefits are achieved.
I support the campaign and the essence of Mrs Eadie’s motion, and I look forward to hearing from the minister on whether, in order to provide an impetus, there needs to be a HEAT target to ensure that material progress is made.
12:56
Like others, I congratulate Helen Eadie on securing time for what has been, although short, a very interesting debate focusing on a couple of specific issues. I had not anticipated that the debate might include the possibility of a Robertson-Baillie duet or the spectre of Michael Forsyth, but I am more than happy to acknowledge the work that Michael Forsyth undertook when he was in a position to do so.
If Michael Forsyth is Voldemort, is the minister Harry Potter?
I would obviously need to get the glasses, but I will take that as a compliment.
Heart disease has been a clinical priority for the Scottish Government and for NHS Scotland for more than 15 years now. Over that period, thanks to the dedication of the staff within the NHS, we have achieved a dramatic 60 per cent decrease in the number of premature deaths from heart disease. As I am sure everyone agrees, that has been achieved through the fantastic efforts of our NHS staff.
Jackson Carlaw is correct that such achievements bring additional challenges. As more people survive heart attacks and live with heart disease, there is a need for more access to high-quality rehabilitation and support. Those needs have been recognised both within the NHS and by campaigning organisations such as Chest, Heart and Stroke Scotland and the British Heart Foundation, which have a long-standing commitment to cardiac rehabilitation.
The key messages from those organisations’ campaigns were incorporated into our “Better Heart Disease and Stroke Care Action Plan”, which places a greater emphasis on the importance of proper support following an acute episode of treatment. The action plan recognises the wealth of evidence supporting the clinical effectiveness and cost-effectiveness of cardiac rehabilitation, which several members have referred to. The importance of cardiac rehabilitation is also echoed in Scotland’s SIGN guidelines and in the clinical standards for heart disease.
Put simply, cardiac rehabilitation is an inexpensive treatment that saves lives. We want everyone who could benefit from cardiac rehabilitation to get appropriate access, and we want to ensure they have the best possible chance of a full recovery.
In recent years, we have been making excellent progress towards achieving that goal. According to ISD Scotland, uptake of cardiac rehabilitation for people with either myocardial infarction or a cardiac intervention has increased from 45 per cent in 2006 to 65 per cent in 2011. Equally impressive is the evidence that shows the high quality of services now being delivered in Scotland. Most areas have a full range of psychosocial, health, lifestyle and medical risk management provisions in place—all areas that were recently highlighted in the BACPR standards.
The audit findings have triggered a range of improvement works in services, and I want to see evidence of further improvements by all boards when further audit results are published later this year. Like BACPR, we want to ensure that cardiovascular prevention and rehabilitation services are safe, effective and person centred. The revised BACPR standards emphasise the need for rehabilitation to be provided in a way that meets an individual’s needs. That fits the Scottish Government’s person-centred approach to the delivery of healthcare, and it is reassuring that the audit found that many NHS boards already offer a menu-based approach to cardiac rehabilitation.
The national advisory committee on heart disease has already identified cardiac rehabilitation as a priority. As part of our heart disease programme, we have supported the most comprehensive audit of cardiac rehabilitation ever undertaken in Scotland; provided some £20,000 funding to the Angus activity programme for people with a long-term condition; and funded the development of an online version of the Lothian heart manual.
There remains much more to do. Helen Eadie is correct to highlight that the clinical standards for heart disease are clear that all people with heart failure and acute angina should be assessed for their suitability for cardiac rehabilitation. We know that referral rates for those groups continue to be low. Rehabilitation services in NHS Scotland are working to address that through service redesign. They are implementing a menu-based approach, anticipating that that will enable an increase in service capacity. I expect the work, which is being developed by boards, to achieve improved outcomes for patients.
We also need to look at the rehabilitation services that can, and should, be made available for people with heart failure and unstable angina. Only a proportion of heart failure and angina patients will be suitable for cardiac rehabilitation programmes that are based in secondary care. It is essential that people with heart failure and angina get the support that they need in their homes and communities.
Clearly, there remains further scope for promoting exercise for people with cardiovascular disease and, indeed, other long-term conditions within the community, particularly within our leisure centres. There are several examples of excellent programmes, including one in Lanarkshire, and I want to see those approaches explored further and rolled out elsewhere.
In terms of our next steps, I have asked our national advisory committee to consider, at its next meeting in February, how we ensure that people with heart failure and acute angina get the support and rehabilitation that they need. The establishment of a new heart failure group will support that process. The development of a HEAT target proposal for cardiac rehabilitation is one of the options that I will ask the group to consider.
The revised BACPR standards make clear the importance of on-going audit. The enthusiasm for the previous audit was extremely heartening. We have therefore explicitly committed NHS Scotland to the on-going monitoring of the provision of cardiac rehabilitation. A further audit report will be issued later in spring.
We have provided substantial funding to Chest, Heart and Stroke Scotland, the British Lung Foundation and the British Heart Foundation Scotland on a programme aimed at supporting people with conditions, including those with heart failure and acute angina, to access appropriate exercise and support. I expect to provide further information to Parliament on that later in the year.
I thank NHS Scotland staff for all the work that they have done to improve the care of people with heart disease. I restate the Government’s commitment to supporting on-going improvements in cardiac services, including rehabilitation services.
13:04
Meeting suspended.
14:30
On resuming—