Inequalities in the Training and Implementation of Cardiac Rehabilitation in the United Kingdom


Cardiovascular disease is the leading cause of morbidity and mortality in the United Kingdom (UK) and although the UK mortality rate has steadily declined since the early 1970′s, the rate of premature death has fallen less than other European countries. Following a cardiac event, it is common for patients to experience debilitating physiological and psychological impairment. A reduced functional capacity and depression are frequent, which is associated with a worse outcome as well as directly impacting on the failure to return to work. Comprehensive cardiac rehabilitation is a multidisciplinary service that provides the majority of cardiac patients with long-term exercise prescription, education, cardiovascular risk factor modification, counselling and medical evaluation to facilitate recovery and improve overall functional capacity following a cardiac event. The provision of cardiac rehabilitation services has grown significantly and demonstrated improved patient health, increased exercise capacity, reduced overall mortality and reduced hospitalisation costs. However, this growth has not been matched by service quality with many programmes unable to adhere to national guidelines due to inadequate resources and the related inability to provide appropriate staff training. Deficiencies in cardiac rehabilitation provision are generally due to inadequate investment, professional barriers, and the relatively low level of priority directed to the service in many cardiology departments. It appears that efficient comprehensive cardiac rehabilitation for patients is a postcode lottery, with substantial variation in the management, organisation, and practice throughout the UK.

Inequalities in the Training and Implementation of Cardiac Rehabilitation in the United Kingdom

Cardiovascular disease (CVD) is the leading cause of morbidity and premature mortality in the United Kingdom (UK) (Dalal and Evans 2003) and accounts for approximately 198,000 deaths each year (Allender 2008). The UK persists as one of the worst developed European countries for CVD mortality and as such the Government has set appropriate targets to reduce the epidemic (Allender 2008). However, despite Government recognition of the health impact, the associated health care costs and development of sophisticated interventions that ultimately aim to restore patient functional capacity, CVD is estimated to remain the highest ranked cause of death worldwide through to 2020 (Murray and Lopez 1997). With this in mind, the need and demand for health care services is increasing disproportionately compared to the available resources. This is primarily due to an ageing population, the development of new knowledge and technology, increasing patient expectations and greater professional expectations (Thompson and Stewart 2002).

Due to improved medical intervention and revascularisation, increasing numbers of patients are living with CVD and after the acute phase of care, the majority of patients require longer-term management and rehabilitation in order to restore their functional capacity and in many to return to work (Stokes 2000). Cardiac rehabilitation (CR) is a multidisciplinary service that provides the majority of cardiac patients with long-term exercise prescription, education, cardiovascular risk factor modification, counselling and medical evaluation (Balady et al. 2000) and is increasingly recognised as a core component of the continuum of care for patients with CVD (Balady et al. 2007; Leon et al. 2005; Wenger et al. 1995). As such the provision of CR services has grown considerably in recent years and is now recommended as useful and effective (Class 1) by the American Heart Association (AHA) and the American College of Cardiology in the treatment of patients with forms of CVD (Antman et al. 2004; Balady et al. 2007; Braunwald et al. 2002; Gibbons et al. 2003; Hunt et al. 2005).

In the UK, comprehensive CR is divided into four phases (Bethell et al. 2009) and programmes target improvements in both physiological and psychosocial aspects of recovery from cardiac injury or intervention to improve/restore patient functional capacity. Physiological parameters include improved exercise tolerance and adherence, cessation of smoking, and optimisation of coronary artery disease (CAD) risk factors, such as body weight, blood pressure and lipid profiles. Psychosocial aspects include the amelioration of negative emotional repercussions of cardiac trauma, such as stress, anxiety and depression and the appropriate return to occupation, which is considered beneficial for both the individual and society (Wenger 2008). The range of knowledge and skills necessary to manage and address the physiological and psychosocial elements is extensive and requires multidisciplinary guidance from cardiologists, clinical exercise scientists, nutritionists, nurses, physiotherapists, psychologists, occupational therapists and social workers (Stokes 2000).

Traditionally, most patients recruited onto CR programmes were patients following a myocardial infarction (MI) or coronary artery bypass graft (CABG) surgery. However, in the era of evidence based health care, contemporary use of CR services include patients following percutaneous coronary intervention (PCI); heart or heart and lung transplantation recipients; patients with stable angina or stable chronic heart failure (CHF); those with peripheral arterial disease (PAD) with claudication; and patients following cardiac surgical procedures for heart valve repair or replacement (Wenger 2008). As a result CR has evolved into a much broader-based multidisciplinary service requiring a range of knowledge and skill mix to achieve the desired outcomes. However, while this is embraced, demands and expectations have been increased without adequate funding targeted at service provision. Additionally, the needs, expectations, and experiences of patients and health care professionals as well as the local resources, priorities, and performance management of CR services are different throughout the UK (Thompson 2002). Furthermore, the National Health Service (NHS) is continually facing financial challenges and CR services are not a priority, despite investment in cardiac technology and intervention. Indeed, the British Heart Foundation (BHF) detailed that the outlook for CR programmes are less secure than in 2006, despite support from the governments national director for heart disease and stroke (BHF 2007).

The patient uptake in CR services throughout the UK and Europe is inadequate (Beswick et al. 2005; Bethell et al. 2001; Kotseva et al. 2009; Kotseva 2004; Wood et al. 2008) and is underrepresented by ethnic minorities, women, older people, and patients living in socially deprived areas (Beswick et al. 2005; Jackson et al. 2005; McGee and Horgan 1992; Taylor et al. 2001; Tod et al. 2001). Commonly, individuals with the greatest functional impairment who are most likely to significantly benefit from CR services do not participate in programmes (Harlan et al. 1995). The culmination of these factors has been previously described as a collective failure of medical practice (Wood et al. 2008).

Cardiac rehabilitation is a cost effective (Bethell et al. 2009; BHF 2007; Levin et al. 1991; Oldridge et al. 1993; Papadakis et al. 2005) proven evidence based intervention, which significantly reduces hospitalisation costs and improves cardiovascular disease risk factors (Clark et al. 2005; Taylor et al. 2004; Thompson 2002; Zwisler et al. 2008). Programmes are now firmly established in the UK and involvement of a multidisciplinary team is paramount in the delivery of a broad range of CR interventions (Child 2004). However, CR suffered from a lack of national direction (Child 2004), until the British Association of Cardiac Rehabilitation (BACR) (Coats 1995) and the Department of Health (DoH) published the National Service Framework (NSF) for Coronary Heart Disease guidelines (DoH 2000b), which sets explicit standards for implementing secondary prevention measures and the provision of effective CR programmes (Dalal and Evans 2003).

Despite evidence of the effectiveness of CR and the introduction of the NSF guidelines, there is support to suggest wide variation in the provision, practice, organisation and management of CR services in the UK (Davidson 1995; O’Driscoll et al. 2007; Stokes 2000; Thompson et al. 1997) with failure to meet the national guidelines (Bethell 2000; BHF 2007; O’Driscoll et al. 2007; Thompson et al. 1996) and the fact that few physicians play an active role and/or endorse CR programmes (Bethell et al. 2009; Jackson et al. 2005; Lewin et al. 1998). Involvement of a clinical lead, such as a consultant cardiologist or general practitioner (GP) with a specialist interest in cardiology as occurs in other European countries may improve facilitation and provision of CR services (Bethell et al. 2009). In addition, health outcome studies consistently demonstrate gaps in applying the clinical evidence of CR into practice, which contributes to sub-optimal patient outcome (Clark et al. 2005; Majumdar et al. 2004). Support for and active referral to CR programmes from the patients doctor is an effective way to encourage CR attendance (McGee and Horgan 1992). Furthermore, education on the benefits and application of CR may improve referral and uptake (Bittner et al. 1999).

The majority of CR programmes in the UK have been initiated, co-ordinated, and delivered by nurses (Stokes 2000; Thompson and Stewart 2002) with the earliest programmes developed during the 1970s. Between 1989 and 1999 there was a rapid growth in the number of CR programmes (six-fold increase) and now every hospital in the UK who treats acute cardiac problems are able to access CR services (Bethell et al. 2009) with the majority remaining hospital based. However, this field is relatively undeveloped as a speciality in terms of an established training or career pathway and the nurses involved in the majority of CR programmes have developed from different career backgrounds with varying degrees of experience or training in cardiac care (Stokes 2000). In taking on new roles and responsibilities, many of which evolved spontaneously and without any methodical design or forecast, there is a risk of health care professionals and in particular nurses focusing exclusively on particular aspects of medical intervention (individual knowledge strengths) rather than concentrating on the entirety of patient care (Thompson and Stewart 2002). As a result the provision of CR services throughout the UK is extremely diverse (O’Driscoll et al. 2007; Stokes 2000) and the configuration of the multidisciplinary health care team is variable (Davidson 1995; Thompson et al. 1997) with minimal input from disciplines other than nursing and physiotherapy (Stokes 2000). Indeed, in a random sample of 120 CR programmes the individual contact with patients was provided by nurses and physiotherapists, with other disciplines mainly involved during lectures or group discussions (Lewin et al. 1998). Furthermore, of the CR programmes within the UK, only 60% had a physiotherapist, 20% had a dietician, and 10% had a psychologist (Bethell et al. 2009). However, this may simply be a reflection of insignificant funding or inadequate planning and organisation.

The need for specialist health care professionals being associated with CR programmes is essential for optimal patient outcome. This is particularly evident in the lack of psychological support available for patients during rehabilitation. Following a cardiac event, depression is common and extremely debilitating. Indeed, patient perceptions of symptoms and their sense of control are significantly associated with quality of life (Lau-Walker et al. 2008) and a depressed mood is a predictor of returning to work following a cardiac event (Bhattacharyya et al. 2007). Therefore, the management of early depression may promote the resumption of employment and enhance the quality of life of cardiac patients (Bhattacharyya et al. 2007). Furthermore, continuous adjustment of goals/tasks during CR, such as increasing exercise intensity and improving self-confidence is positively related to increased cardiopulmonary fitness, reduced depression, weight loss and return to work (Burns and Evon 2007).

The nursing role in CR services did not significantly develop until the late 1980′s and it’s this paradigm shift that has changed nursing care to a holistic model. The diversity of CR programme personnel is directly influenced by the rapid, continual adjustments in medical health care, especially advancing technology and the emergence of how important multifaceted CR services are in patient rehabilitation from cardiac injury/disease or intervention. Therefore the level of education and qualifications attained by CR health care professionals may vary significantly (Bennett and Pescatello 1997). In addition, the change from disease orientated care, such as working on a coronary care ward, to health orientated care, such as the reinforcement of behaviour change, which is necessary for effective and comprehensive CR services, may be challenging for many nursing personnel (Stokes 2000).

Due to the changing roles and identities of health care professionals working within CR services, research suggests that the training and experience already acquired, may not completely equip them for such expanded roles in co-ordinating, delivering, and auditing care directed at health promotion and chronic disease management (Wiles 1997). The changing health care professionals’ roles due to for example, the introduction of rehabilitation services may impact negatively on their own individual motivation and morale, which may significantly influence the patient’s return to health (O’Driscoll et al. 2007). Indeed, nurses report a lack of preparedness for educative, managerial, and leadership roles, which may result in disengagement from and disinterest in their work and contribute to the development of an unhealthy working environment (Conway et al. 2006). Furthermore, job dissatisfaction appears common within the nursing profession (Solman et al. 2004) with up to 24% of nurses reporting decreased job satisfaction and commitment (McNeese-Smith and van Servellen 2000).

Adequate training is required to prepare and equip health care professionals for their individual and multidisciplinary role in educating and supporting patients. Indeed, the inadequate training and lack of professional accreditation available for CR service provision may be one of the major influences on patient recruitment, adherence, and outcome within the UK. In addition, inadequate staff training can result in blurred objectives as well as undefined roles, identities, and skills of health care professionals (O’Driscoll et al. 2007; Stokes 2000). In contrast to the United States of America (USA), programme accreditation has not been established and core competences for health care professionals working in CR programmes have not been formally identified within the UK (Stokes 2000). Despite the arguments surrounding health care professionals and their ability to provide best practice CR services, there is an open debate as to whether or not pre-registration nurse training competently prepares nurses for clinical practice as a whole, since there is no blueprint for nurse education or for the quality of nursing education (Bradshaw 1997). However, despite the USA having advanced and established infrastructure for their CR services, in a study analysing 108 CR programmes, only 40.7% of the staff reported that they met the minimum training/qualification recommendations and only 7% met the preferred recommendations (Bennett and Pescatello 1997).

Changes within the NHS have resulted in a subsequent drive for new and innovative nursing roles (DoH 2000a, c). This has resulted in a change in skill mix (Jenkins-Clarke et al. 1998), where nurses are increasingly being employed instead of doctors in some areas of work (Pearson 1998). These changing roles and identities across professional boundaries within the NHS, creates a culture of uncertainty that has the potential to both inspire and threaten innovation in health care (Williams and Sibbald 1999). In recent years, Government pressure to improve the cost effectiveness of health care provision has focused attention on the possible benefits of moving care from expensive to cheaper providers, in particular from doctors to nurses. The subsequent boundary changes may create uncertainty in relation to professional identity in connection with aspects of the health care professionals work and/or role. This highlighted uncertainty is not limited to displacement of work between doctors and nurses, but also creates tension between different groups of health care professionals due to the potential overlap with other disciplines (Williams and Sibbald 1999), which may be more common in CR programmes due to its multidisciplinary nature, such as exercise prescription, nutritional advice, and psychological support etc. The tension and uncertainty between different groups of staff leads to a loss of professional networking and support, which can lead to demoralization and a sense of diminished autonomy (Hiscock 1996). This in turn, may lead to a breakdown in communication between colleagues and different health care professionals undermining each other as well as leaving both staff and patients feeling extremely vulnerable (O’Driscoll et al. 2007; Williams and Sibbald 1999). Indeed multidisciplinary learning is perceived as beneficial; however little evidence exists of this working in practice and potential barriers include structural and organisational difficulties and failure to agree common aims (Stokes 2000). The need to address how uncertainty and, therefore, changing roles and identities can inspire rather than threaten innovation in health care is critical.

Current educational preparation of nurses, whether at pre-or post registration levels, generally fails to prepare practitioners to play a more prominent role in rehabilitation programmes (Stokes 2000). Furthermore, with few opportunities available in the UK for a structured learning programme specifically developed for CR and with no system of evaluation or accreditation for those that do train it is not surprising to see such diversity throughout the UK in service provision. Providing specialist training for CR programme facilitators and empowering health care professionals with the ability and skills to transfer knowledge across professional boundaries and into different health care settings may improve the safety and quality of patient care and could be one answer to further improving CR services. Future development is necessary and will require greater emphasis on training and education in CR service provision.


Comprehensive CR is essential within the continuum of care for patients with cardiovascular disease for the restoration of functional capacity, regardless of age or gender. Contemporary CR is a proven evidence based intervention that reduces CVD risk factors and may significantly reduce the current CVD epidemic in the UK. The multifaceted composition of CR requires extensive knowledge and skills in order to deliver and achieve nationally recommended objectives. In the UK, current expertise and experience of health care professionals involved in CR provision is inadequate. Furthermore, there is substantial variation in the management, organisation, content, staffing and funding of CR programmes with no formal training throughout the UK. This may directly impact on patients and create the prospect of obtaining efficient comprehensive rehabilitation from cardiac injury or intervention a postcode lottery.

Cardiac rehabilitation programme development appears to have occurred without structured planning with the general outcome of disorganized service provision. As such there is a general lack of aligned roles and identities amongst health care professionals and without adequate modifications to CR infrastructure there is a danger of increased levels of dissatisfaction and high attrition rates within the nursing profession.

To improve CR service provision, a review of the education process, professional development opportunities, and overall training is required. Continual education and training to develop health care professionals is paramount for CR service progression. This process is complex and will need to address role function and boundary crossover as well as be coordinated throughout the UK with specific qualifications, core competencies, and programme and individual accreditation processes in place. Continued evaluation and monitoring of this logical approach will be necessary to ensure that the health care professionals involved in CR provision are adequately trained to deliver nationally recognised care.

It is vital for greater investment and improved planning to permit professional development and enable current and future CR service providers the ability to align their specialist roles with the direction in which health care is moving.

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