Purpose and context

Purpose of this guidance

This guidance is for integrated care boards (ICBs) responsible for the commissioning and oversight of cardiovascular rehabilitation services in England. It sets out the patient cohorts that should be prioritised in cardiovascular rehabilitation services when capacity is significantly below demand, and the key areas that need to be considered when commissioning or delivering services to maximise patient outcomes.

It replaces the Department of Health and Social Care’s (DHSC’s) cardiac rehabilitation guidance (2010), but is not intended to replace clinical guidelines on cardiovascular rehabilitation, which are  set out in the British Association for Cardiovascular Prevention and Rehabilitation’s (BACPR) Standards and Core Components document (2023).

National context

There are around 6.4 million people living with cardiovascular disease in England. It causes a quarter of all deaths and is the largest cause of premature mortality in deprived areas.

Referral, access and uptake of cardiovascular rehabilitation services varies across England. Only half of all eligible patients (60,877 of 122,277) in 2017/18 took up offers of cardiovascular rehabilitation. Scaling up and improving access to 85% of the eligible patients will prevent 50,000 premature deaths and 140,000 acute admissions over 10 years.

Current evidence supports cardiovascular rehabilitation as a cost-effective intervention and demonstrates value for money of both in-person and remote models of delivery. However, not all cardiovascular rehabilitation programmes meet the seven key performance indicators set by the National Certification Programme for Cardiac Rehabilitation (NCP_CR). These include a timely and tailored cardiovascular rehabilitation programme delivered by a multidisciplinary team  with provision for all priority patient groups. The certification report for 2024 showed that just over half of the 184 cardiovascular rehabilitation programmes in England (51%) achieved certification status.

Definition

BACPR 2023 guidance defines cardiovascular rehabilitation as: “The coordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease”.​

Scope

A cardiovascular rehabilitation programme is designed to meet the needs of appropriate patient populations with cardiovascular disease and should be offered, irrespective of age, gender or ethnic group.

It is recommended that local policy emphasises the need for priority groups to be provided for in the first instance. This will reduce variation while ensuring access is equitable, and a consistent service is provided.

Eligibility

Where services have insufficient capacity to meet local demand for cardiovascular rehabilitation programmes, the following patient cohorts should be prioritised for referral to cardiovascular rehabilitation services, in line with NICE guidance:

• acute coronary syndromes [NG185]
• coronary revascularisation​ (percutaneous and surgical interventions) [NG185]
• chronic heart failure in adults [QS9]

Additional patient groups

If there is adequate capacity for the above priority groups, the following additional patient groups can also be offered, as per BACPR Standard 1. For example: ​

• stable angina
• pre and post implantation of cardiovascular defibrillators and resynchronisation devices
• post heart valve repair/replacement
• post heart transplantation and ventricular assist devices
• Adult congenital heart disease (ACHD)

Service delivery

Service aims and objectives

The aim of the service is to offer an inclusive, culturally aligned, personalised intervention to help reduce the risk of secondary cardiovascular events and promote the return to a full and active life following a cardiovascular event/diagnosis.​

The objectives of the service are to:​

• provide a cost-effective, quality-assured cardiovascular rehabilitation programme, that is delivered to patients via a variety of modes, allowing access to be as flexible as possible
• work to improve referral, uptake and adherence rates for all eligible patients
• engage with patients from areas of high deprivation, ethnic minority groups, and other groups who face barriers to accessing rehabilitation
• give patients the tools to lead the fullest lives possible, helping them to regain the skills and abilities that will help them retain or regain their independence
• ensure that the cardiovascular rehabilitation programme works to meet and retain the quality standards of the national certification programme
• deliver a positive patient experience

Delivery modes

Cardiovascular Rehabilitation is provided using any of three delivery modes, with a range of options to suit personalised needs (British Heart Foundation/BACPR personalised cardiac rehabilitation pathway):

• In person: a structured programme delivered in a hospital or community setting
• Remote:
  • web-based
  • phone-based
  • app-based: dedicated application on a mobile device (smartphone, tablet, etc)
  • manual-based: the patient interacts with their rehab programme by following a facilitated manual-based intervention
• Hybrid: a combination of in person and remote

Patients should be supported to switch between these different cardiovascular rehabilitation delivery modes as required throughout their journey.

Personalised cardiovascular rehabilitation pathway

The BACPR standards and core components guidance (2023) on cardiovascular rehabilitation provides evidence-based guidance for the patient pathway within a cardiovascular rehabilitation service. The programme should be tailored to a patient’s individual preferences, needs and circumstances. Service delivery should aim to follow the national standards and deliver the core components set out in the above BACPR guidance and summarised below.

Standards

The 6 standards set out the process: from the identification of appropriate patients and the rehabilitation process, to final assessment, discharge and long-term management.

• Standard 1: Identification and referral
• Standard 2: Multidisciplinary team (see Workforce and Governance section) please add link)
• Standard 3: Initial assessment
• Standard 4: Delivery of programme
• Standard 5: Final assessment
• Standard 6: Audit and evaluation (see audit, evaluation and certification section) please add link)

A summary of the key patient related standards is given below.

Standard 1: Identification and referral

Programmes should be able to provide services for priority groups as set out in the eligibility section above and can extend their offer to other patient cohorts where capacity is available. A clear referral process should be in place and patients should be contacted by the provider within five working days of receiving the referral. Programmes should offer rehabilitation to eligible patients irrespective of their demographic group and promote to them the benefits of attending and completing cardiovascular rehabilitation. 

Standard 3: Initial assessment

Patients should receive a holistic, person-centred initial assessment that takes account of individual needs, participation preferences, choices and co-morbidities.

The assessment should include:

• demographic information
• social health determinants
• discussion and education about diagnosis, medications and lifestyle risk factors
• psychological, physical and behavioural assessments
• medical risk management, e.g. blood pressure, lipids and glucose
• consideration of the ability to make desired lifestyle changes

It should also provide an ongoing agreed plan of care that promotes lifetime skills to assist in self-management of this long-term condition and positive lifestyle changes.

The assessment should start within 10 days of the receipt of referral.  

Standard 4: Delivery of programme

This should be person-centred to meet the patient’s needs, priorities and preferences. Effort should be made to support the patient’s participation in the programme through to completion, offering a variety of delivery modes to give the patient choice. It should be commenced as soon as possible following the initial assessment, deliver evidence-based interventions and address the individuals needs across all relevant core components. 

Standard 5: Final assessment

The final assessment is a core part of the cardiovascular rehabilitation programme as recommended by BACPR standards. It is carried out to determine the extent to which a patient has achieved their goals and the progress made since the initial assessment. This includes changes to lifestyle risk factors such as exposure to tobacco, psychosocial health, for example, anxiety and depression, and medical management of areas such as blood pressure. It provides the basis for developing the patient’s discharge plan with long term strategies and personalised goals.

Core components

Beyond the standards, BACPR sets out five core components to guide implementation of the national guidance and strategies. These are intended to help providers ensure patients’ physical health and quality of life are improved, while equipping patients to self-manage their condition. The five components are:

1. Health behaviour change and education
2. Lifestyle risk factor management, including:

• physical activity and exercise training
• healthy eating and body composition
• tobacco cessation and relapse prevention

3. Psychosocial health
4. Medical risk management
5. Long-term strategies

Guidance on how the core components should be delivered using the latest evidenced practice can be found at BACPR standards and core components 2023.

Delivery of the programme should be through a biopsychosocial evidence-based approach, taking into consideration cultural and individual needs and preferences, as highlighted by the British Heart Foundation’s Cardiovascular Rehabilitation: A participant’s perspective (2022).

What should a comprehensive programme include?

The programme should offer the following, using a variety of modes of delivery to suit patient needs. Patients should be able to access the programme in a flexible manner.

• A full personalised initial assessment. ​[Please refer to standard 3 (initial assessment) of the BACPR standards and core components.]
• Pathophysiology of cardiovascular disease and symptoms.
• A structured exercise programme, incorporating prescribed aerobic and resistance exercises supported by health professionals who have the relevant skills and experience.
• Cardioprotective diet and weight management.
• Tobacco cessation and relapse prevention.
• Self-management and behavioural change of other risk factors, including blood pressure, lipids and glucose.
• Medicines optimisation to ensure maximal management of high or low blood pressure, lipids and glucose.
• Psychological and emotional self-management.
• Stress management techniques (relation, mindfulness).
• Vocational advice, social care and benefits advice.
• Basic Life Support such as cardiopulmonary resuscitation (CPR) and the use of defibrillators.
• Psychosocial health​ management.
• Medical risk management and risk factor management.
• Long term strategies.

A tailored intervention should consider the contributions that family members and carers can make to a patient’s cardiovascular rehabilitation journey. Specific carer support groups could be considered to focus on the issues partners or carers may encounter in coping with their family member’s cardiovascular condition.​

Providers should have a mechanism for re-offer and re-entry into rehabilitation.

Throughout the programme, services should aim to use standardised terminology – as per the BHF/BACPR consensus of key terminology – to ensure a consistent message to patients.

Maximising impact through integrated services

Cardiovascular rehabilitation services must collaborate closely with primary, secondary, and intermediate care providers – such as diagnostic services, community teams and social care agencies – to optimise patient referrals and uptake rates, ultimately benefitting patient outcomes.

We expect referral pathways to be wider than hospital settings. They will include primary and community service teams, particularly for heart failure patients diagnosed outside acute settings.

Cardiovascular rehabilitation services should actively consider collaborating with national and local partners, including charities, to enhance patient support and education.

By partnering with these organisations, patients can access a wealth of online information and educational materials tailored to their specific needs and bettering understanding of their condition, treatment options, and the lifestyle modifications necessary for optimal heart health.

Services should explore partnerships with other organisations to improve cross sector working between primary and secondary care, and link with appropriate community groups. Services should work closely with primary care and local community groups to provide post-discharge care for patients. Through partnerships with these organisations, patients can receive seamless referrals for ongoing support and rehabilitation.

Equality and diversity

The service provider shall ensure the service offered is respectful and does not discriminate on grounds of age, sexual orientation, disability, gender, transgender, race and ethnicity, religion or belief and social deprivation.

Services should strive to improve access for patients with barriers relating to factors such as language, disability, remote locations, digital exclusion, low activation levels and homelessness, by providing alternative options and adaptations.

Outreach work, such as stalls and educational sessions in places where target groups meet, can be effective (see Appendix A).

A personalised approach to cardiovascular rehabilitation is encouraged and can help address cultural needs, such as going for prayers or marking important days for religious or cultural reasons, instead of attending cardiovascular rehabilitation sessions.

The provider has a duty to undertake equality and health inequality impact assessments as a requirement of equality legislation. The provider will co-operate with the commissioner’s equality impact assessments process.

Confidentiality

The service provider will be expected to demonstrate that the collection, storage and transfer of information to other services, including that in electronic format, is secure and complies with all data protection requirements.

Quality and performance standards

Audit, evaluation and certification

The National Audit of Cardiac Rehabilitation (NACR) is commissioned by NHS England to act as the official national audit body reporting on the quality of cardiovascular rehabilitation in England, Wales and Northern Ireland.

The National Certification Programme for cardiovascular rehabilitation is a joint project between the NACR and BACPR. The Programme certifies all cardiovascular rehabilitation services against published minimum standards in England, Northern Ireland and Wales.

BACPR standard 6 (audit and evaluation) sets out audit requirements:

• Formal audit and evaluation shall include service level and patient level data at baseline (pre cardiovascular rehabilitation) and on completion (post cardiovascular rehabilitation) with an emphasis on clinical outcomes, patient experience and satisfaction.
• To monitor the quality of service delivery, and to clearly demonstrate clinical outcomes, every service shall routinely submit timely audit data to NACR.​
• Every rehabilitation service should strive for a high quality service for all patients; and in doing so, should aim to meet the minimum standards set out as part of the National Certification Programme. The quality of cardiovascular rehabilitation is evaluated annually and reported in the public domain each year.

Services should measure and report patient experience and make necessary improvements.

The provider will meet and continue to meet any professional and clinical registration standards that apply, and must be able to demonstrate this to the commissioner and hold details of relevant standards; for example, from professional bodies.​

Supporting guidance

• NICE guideline [NG185] – acute coronary syndromes (2020​)
• NICE quality standard [QS99] – secondary prevention after a myocardial infarction(2015​)
• NICE guideline [NG106] – chronic heart failure in adults: diagnosis and management (2018​)
• NICE quality standard [QS167] – promoting health and preventing premature mortality in black, Asian and other minority groups – Quality statement 4: cardiac rehabilitation (2018)
• BACPR standards and core components for cardiovascular disease prevention and rehabilitation (2023)
• BACPR core competences for the health behaviour change and education component (2016)
• BACPR core competences for the physical activity and exercise component of CVPR services (2024)
• BACPR competences for diet component: healthy eating and body composition (2019)

Workforce and governance standards

A comprehensive cardiovascular rehabilitation service should be delivered using the expertise of a range of professionals working as part of a multidisciplinary team (MDT) within their scope of practice (BACPR Standard 2). The service should be led by a senior clinician (e.g. Nurse or Allied Health Professional) with responsibility for coordination, management and evaluation of the service. The service should also have dedicated administrative support. If possible, the service should be supported by a physician with interest, commitment and knowledge in cardiovascular disease prevention and rehabilitation.

Data from the NACR staff survey (2022) shows that the mean number of patients starting cardiovascular rehabilitation for each staff FTE is 65 (standard deviation 36.5), median 59, interquartile range 51.

On average for each staff FTE within the team, 65 patients were supported through cardiovascular rehabilitation per year.

The clinical personnel should be able to provide evidence that they have the experience and qualifications to undertake the cardiovascular rehabilitation related duties and procedures. All personnel providing the service must be competent to provide those aspects of the service for which they are responsible and will keep their skills up to date.

For example, staff responsible for supervising exercise training must have the qualifications and experience through appropriate professional training or training through organisations such as BACPR. See BACPR core competences.

For home-based or digital programmes, staff facilitators must be trained as per the programme protocols, for example, Heart Manual, REACH-HF or Angina Plan training.

Price

The price for cardiovascular rehabilitation has been set and published through the NHS England Payment Scheme.

Currency for cardiovascular rehabilitation is outlined in the published guidance 23-25 NHS Payment Scheme (amended) Annex B Guidance on currencies (england.nhs.uk).

Appendix A: Example of outreach work to improve awareness and uptake of cardiovascular rehabilitation

Provided by Wirral Community Cardiology Service, Cheshire and Merseyside.

Background

As a team we were aware that nationally, people from some ethnic minority groups were less likely to be referred into and attend cardiovascular rehabilitation. We decided that to address this and hopefully improve access, we would forge closer links with our local multicultural centre.

Work done

We called the multicultural centre, introduced ourselves and met with their link person to see how we could address this problem. We would attend their open days with stalls about cardiovascular rehabilitation and explain what it is. We also agreed to come into the centre and provide health education sessions to various groups.

We do this approximately 4 times a year. We have provided educational sessions on risk factors for cardiovascular disease (cardiovascular disease) with the information tailored to the demographic we were presenting to.

For example, when we spoke with the Chinese association group, we included an eat well pagoda which we found online rather than the traditional eat well plate.

We also attended a women’s-only Zumba session where we did blood pressure and pulse checks after the class and provided health advice. As this was a mixed group, we provided information about hypertension and atrial fibrillation in different languages such as Polish, Arabic, Mandarin.

We used these sessions to give the people attending more information about what cardiovascular rehabilitation is and the benefits it has post-cardiac event/diagnosis of heart failure.

We have also agreed to take self-referrals into the service from patients who have attended educational sessions. In addition, we have a named contact for those patients who may wish to self-refer into the service.

Results of outreach work

People who attend the educational sessions have improved knowledge of risk factors for cardiovascular disease, better awareness of cardiovascular rehabilitation and increased potential to self-refer or to start a cardiovascular rehabilitation programme when referred.

Publication reference: PRN01307