BACR Standards:
A Useful Tool?
Jennifer George / Michelle Bull
SWL Cardiac and Stroke Network
Overview
1. Background
2. Our work before the standards
3. How we have used the standards
4. Some Issues
5. Conclusion
Networks
“Should come together to form local
networks of cardiac care, agreeing
detailed locally relevant referral criteria
and care pathways”
CHD NSF (2000)
Networks


The purpose of a network is to guide and
support the services that comprise it and
the people that use them.
Organisations join networks because they
can do what they need to more effectively
together than if they operate alone.
National Stroke Strategy 2007
South West London
Tertiary
Centre
• 7 programmes
• 1 Tertiary Centre
• 4 DGHs
• 2 Community Hospitals
• Task group
Work before the standards
Baseline Assessment
Aim:
 To create an accurate picture of CR provision
 To identify any gaps in the current service across SWL
 To use information to determine a work programme
for the task group.
Method:
All 7 programmes completed the assessment which was
designed against Chapter 7 of the NSF.
Baseline Assessment
Outcomes:
 Staffing levels, team make-up and funding were
variable and did not appear to be based on need.
 All programmes had a waiting list.
 Current data systems did not allow for assessment
against NSF goal of 85% of people with diagnosis of
AMI or revasc being offered cardiac rehabilitation.
Next steps:
An audit to gain an understanding of patient numbers
and patient movement through each programme.
Work before the standards
Retrospective Audit
Aim:
 Justification of service e.g., referral numbers.
 Patient flow and movement through programme e.g., identify
specifics of where they drop out & why.
 Benchmarking
Method:
 One years worth of data
 Patients with either a diagnosis of MI or after Coronary Artery
Bypass Graft, PCI or other intervention (e.g., valve) were
included in line with the NSF.
 Hospital admission data was requested from IT departments
 Data was collected manually by pulling individual patient files.
Assessment & Audit Outcomes



Each programme provided different services to
patients, leading to inequity of provision and making
comparison across the sector difficult
Agreed there was a need for core elements that a
rehab service should include (in line with NSF
standards and latest evidence)
Endorsement of the BACR standards
The Standards
1.
2.
3.
4.
5.
6.
A Co-ordinator who has overall responsibility for
the CR service
A CR core team of professionally qualified staff
with appropriate skills and competences to deliver
the service
A standardised assessment of individual patient
needs
Referral and access for targeted population
Registration and submission to the NACR
A CR budget appropriate to meet the full service
costs
The Core Components

Lifestyle








Physical activity and exercise:
Diet and weight management:
Smoking cessation:
Education
Risk factor management
Psychological status and quality of life
Cardio protective drug therapy and implantable
devices
Long-term management strategy
How we used the Standards?
Assessment tool 1. Lifestyle
I) Physical activity & exercise: CR should
include;
- Risk stratification & baseline assessment
of physical activity status &
exercise/functional capacity 
- Prescription 
- Staffing levels & state the hours of work;
Specialist Nurse 
Specialist Physio 
Dietician 
Pharmacist 
Clinical Psychologist
Audit & Clerical 
1. A Co-ordinator who has overall responsibility for
the CR service 
2. A CR core team of professionally qualified staff
with appropriate skills and competencies to
deliver the service (included in core
components section)
3. A standardised assessment of individual patient
needs 
4. Referral & access for targeted patient population;
- Exertional angina 
- ACS (unstable angina or NSTEMI or STEMI) following
medical/surgical management 
- Before & after revascularisation 
- Following any stepwise alteration in CHD condition 
- Other atherosclerotic disease e.g., peripheral arterial
disease 
- Stable HF & Cardiomyopathy 
- Following implantable device interventions 
5. Registration and submission to the National Audit
for Cardiac Rehabilitation (NACR) database 
6. A CR budget appropriate to meet the full service
costs 
Findings
 Not meeting the standard
 Partially meeting the standard
 Totally meeting the standard
Prog 1
Standard 1
(co-ordinator)
Standard 2
(team)
Standard 3
(assessment)
Standard 4
(pt groups)
Standard 5
(NACR)
Standard 6
(Budget)
Prog 2
Prog 3
Prog 4
Prog 5
Prog 6
Prog 7
What we did with results

Sector wide





Quality assurance role
NACR
Agreed ideal pathway
Increased profile for cardiac rehab
Individual Programmes


Development of new services
Supporting programmes through change
Standard 4
1
Exertional
angina
ACS
Before &
after
revasc
Following
stepwise
alteration
Other
Atheroscle
oticdisease
Stable HF
&
Cardiomyopathy
Following
Implantable
e devices
2
3
4
5
6
7
Programme 2


Standard 4 - ICD pilot
Standard 2 - Business case development for
heart failure
Clinical
lead
Specialist
Nurse
Physio
Dietician
Pharmacist
Clinical
Psyc
Audit &
Clerical
Programme 2
Clinical
lead

Specialist
Nurse
Physio
Dietician
Pharmacist
Clinical
Psyc
Standard 2 – core team development

Regular physiotherapy input
Audit &
Clerical
How we used the standards
 Not meeting the standard
 Partially meeting the standard
 Totally meeting the standard
Prog 1
Standard 1
(co-ordinator)
Standard 2
(team)
Standard 3
(assessment)
Standard 4
(pt groups)
Standard 5
(NACR)
Standard 6
(Budget)
Prog 2
Prog 3
Prog 4
Prog 5
Prog 6
Prog 7
Programme 5




Standard 5 – web based NACR pilot
Standard 4 - PCT secured funding to
develop local community based
programme
Standard 2 - Appropriate staffing levels
Able to advise re appropriate model
How we used the standards
 Not meeting the standard
 Partially meeting the standard
 Totally meeting the standard
Prog 1
Standard 1
(co-ordinator)
Standard 2
(team)
Standard 3
(assessment)
Standard 4
(pt groups)
Standard 5
(NACR)
Standard 6
(Budget)
Prog 2
Prog 3
Prog 4
Prog 5
Prog 6
Prog 7
Programmes 3 and 4



Local programme resourced by staff from
PCT and acute trust
Plans to move phase 3 to community as
part of review of CNS roles
Conflict between providers and
commissioners
Programmes 3 and 4

Core Components





Process mapping
Peer review
Links with other services
Phase 4 mapping
Standard 2

Skills assessment
Where the standards have
caused debate

Definitions




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
ACS
Cardio protective drug therapy
Staffing levels
Budget
Commissioning
Annual review


Who will assess this
“Programme under development”
Are they a useful tool?

Yes

Useful driver to support development work

Support for programmes undergoing change

Informing commissioning
But …….

Need to have strategic commitment at
local level

Need higher national profile

Need agreement re “enforcement”
www.southwestlondoncardiacnetwork.nhs.uk
[email protected]
[email protected]
(020) 8725 2924