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Chronic heart failure

About

What is covered

This interactive flowchart covers diagnosing and managing chronic heart failure in people aged 18 and over. It aims to improve diagnosis and treatment to increase the length and quality of life for people with heart failure.

Updates

Updates to this interactive flowchart

11 September 2018 Major update on publication of chronic heart failure in adults: diagnosis and management (NICE guideline NG106).
10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing chronic heart failure in adults in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing chronic heart failure in people aged 18 and over. It aims to improve diagnosis and treatment to increase the length and quality of life for people with heart failure.

Updates

Updates to this interactive flowchart

11 September 2018 Major update on publication of chronic heart failure in adults: diagnosis and management (NICE guideline NG106).
10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Ivabradine for treating chronic heart failure (2012) NICE technology appraisal guidance 267
Partial left ventriculectomy (the Batista procedure) (2004) NICE interventional procedures guidance 41
ENDURALIFE-powered CRT-D devices for treating heart failure (2017) NICE medical technologies guidance 33
Chronic heart failure in adults (2011 updated 2018) NICE quality standard 9
OCS Heart system for heart transplant (2016) NICE medtech innovation briefing 86

Quality standards

Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups

These quality statements are taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statements

Diagnosis by a specialist

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment.

Rationale

To ensure that the correct diagnosis is made, adults with suspected chronic heart failure who have been referred for diagnosis should have an echocardiogram and be seen by a specialist. The specialist should assess the person and review the echocardiogram results. The echocardiogram will show any valve disease and assess the function of the left ventricle. Specialist assessment is needed to confirm the diagnosis of heart failure, consider the possible causes, discuss the appropriate treatment and develop a management plan.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with suspected chronic heart failure referred for diagnosis have an echocardiogram and specialist assessment.
Data source: Local data collection.
Process
Proportion of adults with suspected chronic heart failure referred for diagnosis who have an echocardiogram and specialist assessment.
Numerator – the number in the denominator who have an echocardiogram and specialist assessment.
Denominator – the number of adults with suspected chronic heart failure who are referred for diagnosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals) ensure that systems are in place so that adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment.
Healthcare professionals (such as doctors and specialists in cardiac care) ensure that adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment. Specialists in cardiac care should assess the person after they have had an echocardiogram.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment.

What the quality statement means for patients, service users and carers

Adults with symptoms of heart failure who have been referred for diagnosis have a test called an echocardiogram to check the structure of their heart and how well it is working. They are then seen by a heart specialist who will carry out an assessment and confirm whether they have chronic heart failure. If chronic heart failure is diagnosed, the specialist will try to find the cause, offer treatment and talk to the person about how to manage their condition.

Source guidance

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendations 1.2.2, 1.2.4 and 1.2.6

Definitions of terms used in this quality statement

Specialist
The core specialist heart failure multidisciplinary team includes:
  • a lead physician with subspecialty training in heart failure (usually a consultant cardiologist) who is responsible for making the clinical diagnosis
  • a specialist heart failure nurse
  • a healthcare professional with expertise in specialist prescribing for heart failure.
[Adapted from NICE’s guideline on chronic heart failure in adults, recommendation 1.1.1]

Urgent specialist assessment within 2 weeks

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with suspected chronic heart failure and very high levels of serum natriuretic peptides, who have been referred for diagnosis, have an echocardiogram and specialist assessment within 2 weeks.

Rationale

Adults who have very high levels of serum natriuretic peptides have a higher likelihood of heart failure and a poorer prognosis. The time taken for diagnostic testing and assessment is particularly important for these patients. Having an echocardiogram and specialist assessment within 2 weeks of referral can help to ensure that the person is started on appropriate medication to reduce any further long term damage to the heart.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with suspected chronic heart failure and very high levels of serum natriuretic peptides, who have been referred for diagnosis, have an echocardiogram and specialist assessment within 2 weeks.
Data source: Local data collection.
Process
Proportion of adults with suspected chronic heart failure and very high levels of serum natriuretic peptides, who have been referred for diagnosis, who have an echocardiogram and specialist assessment within 2 weeks of referral.
Numerator – the number in the denominator who have an echocardiogram and a specialist assessment within 2 weeks of referral.
Denominator – the number of adults referred for diagnosis with suspected chronic heart failure and very high levels of serum natriuretic peptides.
Data source: Local data collection.
Outcome
a) Mortality due to heart failure.
Data source: Local data collection.
b) Hospital admissions, inpatient hospital days and readmissions due to heart failure.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals) ensure that systems are in place for adults with suspected chronic heart failure referred for diagnosis to have an echocardiogram and be seen by a specialist within 2 weeks of referral if they have very high levels of serum natriuretic peptides.
Healthcare professionals (such as specialists in cardiac care) ensure that adults with suspected chronic heart failure referred for diagnosis have an echocardiogram and are seen within 2 weeks of referral if they have very high levels of serum natriuretic peptides.
Commissioners (such as clinical commissioning groups) ensure that they commission services in which adults with suspected chronic heart failure referred for diagnosis have an echocardiogram and are seen by a specialist within 2 weeks of referral if they have very high levels of serum natriuretic peptides.

What the quality statement means for patients, service users and carers

Adults with symptoms of chronic heart failure who have been referred for diagnosis have a test called an echocardiogram and are seen by a heart specialist. This should happen within 2 weeks of being referred by their GP if a blood test shows high levels of a substance (called a ‘serum natriuretic peptide’) that suggests they may have heart failure needing urgent treatment. An echocardiogram is a test to check the structure of their heart and how well it is working. The specialist will carry out an assessment and confirm whether they have chronic heart failure. If chronic heart failure is diagnosed, the specialist will try to find the cause, offer treatment and talk to the person about how to manage the condition.

Source guidance

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendation 1.2.3

Definitions of terms used in this quality statement

Specialist
The core specialist heart failure multidisciplinary team includes:
  • a lead physician with subspecialty training in heart failure (usually a consultant cardiologist) who is responsible for making the clinical diagnosis
  • a specialist heart failure nurse
  • a healthcare professional with expertise in specialist prescribing for heart failure.
[Adapted from NICE’s guideline on chronic heart failure in adults, recommendation 1.1.1]
Very high levels of serum natriuretic peptides
Levels of serum natriuretic peptides (N-terminal pro-B-type natriuretic peptide [NT-proBNP]) in the blood are raised in people with heart failure. Very high levels of serum natriuretic peptides are defined as a NT-proBNP level above 2,000 ng/litre (236 pmol/litre).
[Adapted from NICE’s guideline on chronic heart failure in adults, recommendation 1.2.3]

Medication for chronic heart failure with reduced ejection fraction

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with chronic heart failure who have reduced ejection fraction are started on low dose angiotensin converting enzyme (ACE) inhibitor and beta blocker medications that are gradually increased until the target or optimal tolerated doses are reached.

Rationale

ACE inhibitors and beta blockers are of proven benefit for people with chronic heart failure who have reduced ejection fraction, and taking them at the optimum dose will provide the best outcome. However, ACE inhibitors can cause low blood pressure and renal impairment, and beta blockers can initially make heart failure symptoms worse and cause low blood pressure and a low heart rate. Therefore, people taking these medicines should be started on low doses, and the doses gradually increased, with regular checks to monitor any side effects, until the target or optimal tolerated doses are reached.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with chronic heart failure who have reduced ejection fraction are started on low dose ACE inhibitor and beta blocker medications, which are gradually increased until the target or optimal tolerated doses are reached.
Data source: Local data collection.
Process
a) Proportion of adults diagnosed with chronic heart failure who have reduced ejection fraction prescribed ACE inhibitor medication who are on a dose that is higher than the starting dose.
Numerator – The number in the denominator who are on a dose of ACE inhibitor medication that is higher than the starting dose.
Denominator – The number of adults diagnosed with chronic heart failure who have reduced ejection fraction who are prescribed ACE inhibitor medication.
b) Proportion of adults diagnosed with chronic heart failure who have reduced ejection fraction prescribed beta blocker medication who are on a dose that is higher than the starting dose.
Numerator – The number in the denominator who are on a dose of beta-blocker medication that is higher than the starting dose.
Denominator – The number of adults diagnosed with chronic heart failure who have reduced ejection fraction who are prescribed beta blocker medication.
Data source: Local data collection.
Outcome
a) Mortality due to heart failure.
Data source: Local data collection.
b) Hospital admissions, inpatient hospital days and readmissions due to heart failure.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, hospitals and community providers) ensure that adults with chronic heart failure who have reduced ejection fraction are started on low dose ACE inhibitor and beta blocker medications that are gradually increased until the target or optimal tolerated doses are reached, and that there is monitoring for side effects after each increase in dose.
Healthcare professionals (such as GPs, specialists in cardiac care and heart failure specialist nurses) ensure that when they prescribe ACE inhibitors and beta blockers for adults with chronic heart failure who have reduced ejection fraction, they start with low doses and gradually increase them until the target or optimal tolerated doses are reached. They also ensure that they monitor as a minimum the person’s serum urea, creatinine, electrolytes, eGFR (estimated glomerular filtration rate), heart rate, blood pressure and clinical status after each increase in dose. The multidisciplinary heart failure team will decide on the most appropriate team member to do this, for example, the GP may lead the care in consultation with other members of the team.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with chronic heart failure who have reduced ejection fraction are started on low dose ACE inhibitor and beta blocker medications that are gradually increased until the target or optimal tolerated doses are reached, and are monitored for side effects after each increase in dose.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure who have reduced ejection fraction (when the part of the heart that pumps blood around the body isn't squeezing the blood as well as it should) are prescribed medications for heart failure and high blood pressure (called beta blockers and ACE inhibitors). These are given at low doses at first and increased gradually until the person is taking the ideal dose for their condition, or the highest dose their body can cope with.

Source guidance

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendations 1.4.1, 1.4.3, 1.4.4 and 1.4.13

Definitions of terms used in this quality statement

Heart failure with reduced ejection fraction
Heart failure with an ejection fraction below 40%.
[NICE’s guideline on chronic heart failure in adults]

Equality and diversity considerations

ACE inhibitors are less effective in people of African or Caribbean family origin. Healthcare professionals should take this into account and ensure that the person receives additional treatment promptly if needed.

Review after changes in medication

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.

Rationale

Medication to treat chronic heart failure can cause significant side effects, including dehydration, low blood pressure, a low heart rate and renal impairment. Some may initially and temporarily make heart failure symptoms worse. When the dose or type of medication for chronic heart failure is changed, the person should have a review within 2 weeks to monitor the effects. This can also include a review of the effectiveness of the medication and whether any further changes or referral to other members of the multidisciplinary team are needed.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.
Data source: Local data collection.
Process
Proportion of changes to dose or type of chronic heart failure medication in which the person is reviewed within 2 weeks of a change.
Numerator – the number in the denominator in which the person is reviewed within 2 weeks of the change in medication.
Denominator – the number of changes to dose or type of chronic heart failure medication in adults with chronic heart failure.
Data source: Local data collection.
Outcome
a) Renal impairment.
Data source: Local data collection.
b) Hospital admissions, inpatient hospital days and readmissions.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, hospitals and community providers) ensure that systems are in place so that adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.
Healthcare professionals (such as GPs, specialists in cardiac care, heart failure specialist nurses and specialist multidisciplinary heart failure teams) ensure that they carry out a review for adults with chronic heart failure within 2 weeks of any change in the dose or type of their heart failure medication. The multidisciplinary heart failure team will decide who is the most appropriate team member to do this, for example, the GP may lead the care in consultation with other members of the team.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure are seen by their healthcare professional within 2 weeks of any change in the dose or type of medication they are taking for heart failure, to check for any problems and make sure that the medication is working.

Source guidance

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendations 1.7.1 and 1.7.3

Definitions of terms used in this quality statement

Review when medication is changed
Review should include as a minimum:
  • clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
  • review of medication, including need for changes and possible side effects
  • an assessment of renal function.
More detailed monitoring is needed if the person has significant comorbidity or if their condition has deteriorated since the previous review.
[Adapted from NICE’s guideline on chronic heart failure in adults, recommendations 1.7.1 and 1.7.2]

Review of people with stable chronic heart failure

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with stable chronic heart failure have a review of their condition at least every 6 months.

Rationale

Adults with stable chronic heart failure should have a review of their condition at least every 6 months to ensure that their medications are working effectively and they are not experiencing any significant side effects. This will allow their healthcare professional to assess whether there has been any deterioration in their condition, if their medications should be changed, if other procedures (such as cardiac resynchronisation therapy) should be considered and whether referral to another member of the multidisciplinary team is needed.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with stable chronic heart failure have a review of their condition at least every 6 months.
Data source: Local data collection.
Process
Proportion of adults with stable chronic heart failure who have had a review of their condition during the past 6 months.
Numerator – the number in the denominator who have had a review of their condition during the past 6 months.
Denominator – the number of adults with stable chronic heart failure.
Data source: Local data collection.
Outcome
a) Quality of life.
Data source: Local data collection.
b) Renal impairment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, hospitals and community providers) ensure that systems are in place so that adults with stable chronic heart failure have a review of their condition at least every 6 months.
Healthcare professionals (such as GPs and specialist multidisciplinary heart failure team members) ensure that they review adults with stable chronic heart failure at least every 6 months. The multidisciplinary heart failure team will decide on the most appropriate member to do this, for example, the GP may lead care in consultation with other members of the team.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with stable chronic heart failure have a review of their condition at least every 6 months.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure that isn’t worsening are seen at least every 6 months by their healthcare professional, who will check whether their condition has got better or worse, whether their medication needs to be changed and if other types of treatment might be suitable for them. The person may also be referred to other members of the care team, such as a heart failure specialist nurse.

Source guidance

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendations 1.7.1 and 1.7.3

Definitions of terms used in this quality statement

Review of people with stable chronic heart failure
This should include as a minimum:
  • clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
  • review of medication, including need for changes and possible side effects
  • an assessment of renal function.
For people taking amiodarone the review should include liver and thyroid function tests, and a review of side effects.
The review should also include a discussion about the suitability of a programme of cardiac rehabilitation.
More detailed monitoring is needed if the person has significant comorbidity or if their condition has deteriorated since the previous review.
[Adapted from NICE’s guideline on chronic heart failure in adults, recommendations 1.6.5, 1.7.1 and 1.7.3]

Programme of cardiac rehabilitation

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with stable chronic heart failure are offered an exercise based programme of cardiac rehabilitation.

Rationale

Programmes of cardiac rehabilitation can help to extend and improve the quality of a person’s life through monitored exercise, emotional support and education about lifestyle changes to reduce the risks of further heart problems. They can also reduce uncertainty and anxiety about living with chronic heart failure and, through better management of their condition, the person may have greater opportunities to return to normal activities. Offering an exercise based programme of cardiac rehabilitation to all adults with chronic heart failure when their condition is stable, will help to prevent the person’s heart failure from worsening, reduce their risk of future heart problems and improve their quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with stable chronic heart failure are offered an exercise based programme of cardiac rehabilitation.
Data source: Local data collection.
Process
Proportion of adults diagnosed with stable chronic heart failure who have been referred to an exercise based programme of cardiac rehabilitation.
Numerator – the number in the denominator who have a record of referral to an exercise based programme of cardiac rehabilitation.
Denominator – the number of adults with stable chronic heart failure.
Data source: Local data collection.
Outcome
a) Rates of uptake of and adherence to programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.
b) Patient experience of programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community nursing teams and hospitals) ensure that exercise based programmes of cardiac rehabilitation that include a psychological and educational component are available for adults with stable chronic heart failure.
Healthcare professionals (such as GPs, cardiac rehabilitation nurses and specialists in cardiac care) ensure that they offer adults diagnosed with stable chronic heart failure an exercise based programme of cardiac rehabilitation, once they are well enough to attend.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission services in which exercise based cardiac rehabilitation programmes, that include a psychological and educational component, are offered to adults with stable chronic heart failure.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure that isn’t worsening are offered an exercise based programme of cardiac rehabilitation that is designed for people with heart failure, if it is suitable for them and once they are well enough to attend. This programme will include help and support with taking exercise, understanding their condition and how to look after themselves.

Source guidance

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendation 1.9.1

Definitions of terms used in this quality statement

Programme of cardiac rehabilitation
This is an exercise based programme of rehabilitation designed for people with heart failure that includes a psychological and educational component.
[Adapted from NICE’s guideline on chronic heart failure in adults, recommendation 1.9.1]

Equality and diversity considerations

A programme of cardiac rehabilitation should be available for all adults with stable chronic heart failure, including those who may be house bound or in a nursing home. To ensure equality of access to rehabilitation programmes, measures such as providing transport for people to attend sessions and holding the sessions in different locations should be considered. Cardiac rehabilitation should be held in centres that have access for disabled people.
Healthcare professionals should take into account the communication needs of people with stable chronic heart failure, including those with cognitive impairment, when delivering cardiac rehabilitation. All information should be culturally appropriate, and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People should have access to an interpreter or advocate if needed.

Options for cardiac rehabilitation (developmental)

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.
Developmental quality statements set out an emergent area of cutting edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Adults with chronic heart failure referred to a programme of cardiac rehabilitation are offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.

Rationale

Programmes of cardiac rehabilitation can improve clinical outcomes and quality of life for people with chronic heart failure. People with chronic heart failure are typically older, and may be frail or have comorbidities. This can make it difficult for them to attend group based programmes at hospitals or clinics. Offering programmes of cardiac rehabilitation at different times of day and at different venues is likely to increase both uptake and adherence, and to improve patient experience.

Quality measures

Structure
Evidence of local arrangements to provide programmes of cardiac rehabilitation during and outside working hours, and the choice of undertaking programmes at home, in the community or in a hospital setting.
Data source: Local data collection.
Process
Proportion of people referred to a programme of cardiac rehabilitation who are offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.
Numerator – the number in the denominator offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.
Denominator – the number of adults with chronic heart failure referred to a programme of cardiac rehabilitation.
Data source: Local data collection.
Outcome
a) Rates of uptake of and adherence to programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.
b) Patient experience of programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community nursing teams and hospitals) offer programmes of cardiac rehabilitation during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.
Healthcare professionals (such as GPs, cardiac rehabilitation nurses and specialists in cardiac care) offer adults referred to programmes of cardiac rehabilitation a choice of sessions during and outside working hours, and a choice of undertaking the programme at home, in the community or in a hospital setting.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) commission cardiac rehabilitation services that have the capacity to provide programmes during and outside working hours, and a choice of undertaking the programme at home, in the community or in a hospital setting.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure offered a rehabilitation programme can choose to have their sessions at a time and place that suits them, such as during or outside working hours, and at a hospital or venue in their local area, or at home. This can help people to take part and continue to attend a programme.

Source guidance

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendation 1.9.1

Definitions of terms used in this quality statement

Programme of cardiac rehabilitation
This is an exercise based programme of rehabilitation designed for people with heart failure that includes a psychological and educational component.
[Adapted from NICE’s guideline on chronic heart failure in adults, recommendation 1.9.1]

Equality and diversity considerations

A programme of cardiac rehabilitation should be available for all adults with chronic heart failure, including those who may be house-bound or in a nursing home. To ensure equality of access to rehabilitation programmes, measures such as providing transport for people to attend sessions and holding the sessions in different locations should be considered. Cardiac rehabilitation should be held in centres that have access for disabled people.
Healthcare professionals should take into account the communication needs of people with chronic heart failure, including those with cognitive impairment, when delivering cardiac rehabilitation. All information should be culturally appropriate, and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People should have access to an interpreter or advocate if needed.

Designing health and wellbeing programmes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups have their views represented in setting priorities and designing local health and wellbeing programmes.

Rationale

Health and wellbeing programmes can support positive behaviour changes and contribute to promoting health and preventing premature mortality. People from black, Asian and other minority ethnic groups may not engage with services or may have a poor experience of those programmes and associated services if they are not culturally sensitive and appropriate. Involving people, community organisations and faith leaders who can represent the views of local minority ethnic groups helps to ensure that the services reflect the needs and preferences of the local population.

Quality measures

Structure
a) Evidence of work carried out to gather intelligence about the ethnic diversity of the local population.
Data source: Local data collection, for example, intelligence gathered for the Joint Strategic Needs Assessment.
b) Evidence of work carried out to gain understanding of the needs of black, Asian and other minority ethnic groups living in the local area.
Data source: Local data collection, for example, intelligence gathered for the joint strategic needs assessment.
c) Evidence of actions taken to gather views of local people from black, Asian and other minority ethnic groups on priorities for and design of health and wellbeing programmes.
Data source: Local data collection, for example, from programme planning, records from meetings (agendas or minutes) and focus groups.
d) Evidence of how intelligence on ethnic diversity, the needs and views of the local population is used to inform commissioning.
Data source: Local data collection, for example, information included in local health equality assessments.
Process
a) Proportion of local health and wellbeing programmes that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Numerator – the number in the denominator that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Denominator – the number of health and wellbeing programmes commissioned locally.
Data source: Local data collection, for example, service annual report.
b) Proportion of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes who felt that their views were valued.
Numerator – the number in the denominator that felt their views were valued.
Denominator – the number of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes.
Data source: Local data collection, for example, surveys carried out with people representing ethnic groups.
Outcome
a) Uptake of local health and wellbeing services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, service workflow.
b) Proportion of people from black, Asian and other minority ethnic groups referred to local health and wellbeing services who feel that the services meet their needs.
Data source: Local data collection, for example, service user survey.
c) Prevalence of obesity among local people from black, Asian and other minority ethnic groups.
Data source: NHS Digital’s Health Survey for England and National Child Measurement Programme, and local data collection, for example, GP practice data.
d) Physical activity levels among local people from black, Asian and other minority ethnic groups.
Data source: Active Lives, Sport England and local data collection, for example, review of service user records held by the provider.
e) Prevalence of tobacco use among local people from black, Asian and other minority ethnic groups.
Data source: Office for National Statistics’ Annual Population Survey and local data collection, for example, stop smoking service data.
f) Mental wellbeing among local people from black, Asian and other minority ethnic groups.
Data source: Local health data collection, for example mental health and wellbeing joint strategic needs assessment profile.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that the services they provide recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups. They continually review the services to ensure that they are culturally appropriate, accessible and tailored to the diverse needs of the local population.
Health, public health and social care practitioners recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups that they support. They ensure that the services they provide are culturally appropriate and accessible. This may mean working in partnership with existing local community groups or faith leaders who can support delivering some of the programmes in non-traditional community-based settings.
Commissioners (Public Health England, NHS England, local authorities, clinical commissioning groups) gather intelligence and gain understanding of the diversity of the local population and its needs. They ensure that the views of people from minority ethnic groups are represented when priorities are set and local health and wellbeing programmes are designed. This may be through engaging local communities using public consultation or community workshops that discuss future services. These can ensure that the local population is represented by individuals as well as established community groups and educational or religious leaders. The commissioners also ensure that local services have the skills mix and capacity to provide support that is culturally appropriate and tailored to the needs of people from black, Asian and other minority ethnic groups to make positive behaviour changes.
People from black, Asian and other minority ethnic groups advise on what local health and wellbeing programmes should focus on and what culturally sensitive and acceptable services should look like. They share their views during workshops or consultations organised by the commissioners, or through other people who they trust, such as community leaders or faith leaders.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. Commissioners and providers seeking to obtain the views and understand the needs of people from black, Asian and other minority ethnic groups should work closely with existing community groups, faith leaders and educators who may already have links to groups and individuals with poor access to services.

Peer and lay roles

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups are represented in peer and lay roles within local health and wellbeing programmes.

Rationale

People from black, Asian and other minority ethnic groups are underrepresented in health and wellbeing programmes. To ensure that the programmes are accessed and used by minority ethnic groups, commissioners and providers need to recognise the knowledge, skills and expertise of local communities. People known to and trusted by communities can take on peer and lay roles and encourage uptake of services among groups that may otherwise be reluctant to get involved. They can raise awareness, deliver information and advice in a culturally appropriate manner, and help with designing and providing interventions and services that are relevant, acceptable and tailored to the local population.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups are represented in peer and lay roles for local health and wellbeing programmes.
Data source: Local data collection, for example, from service planning and service design records, and recruitment records.
b) Evidence of local arrangements to support people from black, Asian and other minority ethnic groups taking on peer and lay roles in local health and wellbeing programmes.
Data source: Local data collection, for example, records of meetings, mentoring sessions, existing support networks or workshops with people taking on peer and lay roles.
Process
Proportion of local health and wellbeing programmes with people working in peer and lay roles who are representative of the local community.
Numerator – the number in the denominator with people working in peer and lay roles who are representative of the local community.
Denominator – the number of local health and wellbeing programmes.
Data source: Local data collection, for example, from service annual reports.
Outcome
a) The number of people from black, Asian and other minority groups who access local health and wellbeing programmes.
Data source: Local data collection, for example, review of service records.
b) The number of people in peer and lay roles supporting black, Asian and other minority ethnic groups to improve their health and wellbeing.
Data source: Local data collection, for example, review of service records.
c) Experience of engaging with local health and wellbeing programmes among people from black, Asian and other minority groups.
Data source: Local data collection, for example, service user survey.
d) Long-term retention of people in peer and lay roles.
Data source: Local data collection, for example, service annual report.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that they work with established community groups and educational or religious leaders to identify and recruit members of the local community who can support people from black, Asian and other minority ethnic groups and represent the diverse needs of the local population. They ensure that people in lay roles are supported with resources, information and mechanisms to proactively engage members of the community who may be excluded or disengaged. Service providers also support people in peer and lay roles with feedback, support networks, training and mentoring to allow them to fulfil their responsibilities, reach their full potential and continue with the role.
Commissioners (community and voluntary sector organisations and statutory services) understand the diversity of their local community and make a long-term commitment to funding and supporting effective community engagement approaches, such as peer and lay roles. They secure resources to recruit people to peer and lay roles and provide them with ongoing training and support.
People from black, Asian and other minority ethnic groups are given support and information by other members of their own community who are working closely with organisations that provide local health and wellbeing services. These people represent the interests and concerns of the community and ensure that local health and wellbeing programmes and services recognise the beliefs, expectations and values of people from black, Asian and other minority ethnic groups.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]
Peer and lay roles
Community members working in a non-professional capacity to support health and wellbeing initiatives. 'Lay' is the general term for a community member. 'Peer' describes a community member who shares similar life experiences to the community they are working with. Peer and lay roles may be paid or unpaid (that is, voluntary). Effective peer and lay approaches are:
  • Bridging roles to establish effective links between statutory, community and voluntary organisations and the local community and to determine which types of communication would most effectively help get people involved.
  • Carrying out 'peer interventions'. That is, training and supporting people to offer information and support to others, either from the same community or from similar backgrounds.
  • Community health champions who aim to reach marginalised or vulnerable groups and help them get involved.
  • Volunteer health roles whereby community members get involved in organising and delivering activities.
[NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. People in peer and lay roles may be more successful at engaging with and supporting people from similar backgrounds than traditional health and wellbeing services.

Referring people at high risk of type 2 diabetes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups at high risk of type 2 diabetes are referred to an intensive lifestyle change programme.

Rationale

People from certain ethnic communities have a higher risk of developing type 2 diabetes than those in the white European population. This includes people of South Asian, Chinese, black African and African-Caribbean family origin. In these populations, the risk of type 2 diabetes increases at an earlier age and at a lower BMI level. Many cases of type 2 diabetes are preventable through changes to a person's diet and physical activity levels. Evidence-based intensive lifestyle change programmes can significantly reduce the risk of developing type 2 diabetes for those at high risk.

Quality measures

Structure
Evidence of local arrangements for identifying and referring people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes.
Data source: Local data collection, for example, GP contracts.
Process
a) Proportion of people from black, Asian and other minority ethnic groups identified as being at high risk of type 2 diabetes who are referred to an intensive lifestyle change programme.
Numerator – the number in the denominator who are referred to an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are identified as being at high risk of type 2 diabetes.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).
b) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who attended the programme.
Numerator – the number in the denominator who attended an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
c) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who completed the programme.
Numerator – the number in the denominator who completed an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
Outcome
a) Change in BMI among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
b) Change in blood pressure among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
c) Change in HbA1c among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
d) Prevalence of type 2 diabetes among people from black, Asian and other minority groups.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and Public Health England’s Diabetes prevalence estimates for local populations.

What the quality statement means for different audiences

Service providers (such as GPs and community healthcare providers) ensure that people from black, Asian and other minority ethnic groups who are identified as being at high risk of developing type 2 diabetes are referred to an intensive lifestyle change programme. They also ensure that systems are in place to start diabetes prevention interventions at a lower BMI threshold in people from minority ethnic groups at increased risk of type 2 diabetes. This may involve people in peer and lay roles raising awareness, assessing risks and providing advice on diabetes prevention among those ethnic minorities.
Health and public health practitioners (such as GPs, practice nurses and community healthcare providers) are aware that some black, Asian and other minority ethnic groups have an increased risk of type 2 diabetes. They refer people who are at high risk to an intensive lifestyle change programme and provide advice to those with a lower level of risk.
Commissioners (clinical commissioning groups, NHS England and local authorities in sustainability and transformation partnership areas) ensure that intensive lifestyle change programmes are available for people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes. They work with ethnic minorities to ensure that programmes include a range of culturally sensitive and appropriate behaviour change interventions.
People from black, Asian and other minority ethnic group at high risk of type 2 diabetes are referred to culturally sensitive and appropriate services that can help them achieve healthy weight and be more active. Those who are not currently at high risk of type 2 diabetes are given information and further support relevant to their needs.

Source guidance

Definitions of terms used in this quality statement

Intensive lifestyle change programme
A structured and coordinated range of interventions provided in different venues for people identified as being at high risk of developing type 2 diabetes. It should be local, evidence-based and quality-assured. The aim is to help people to become more physically active and improve their diet. If the person is overweight or obese, the programme should result in weight loss. Programmes may be delivered to individuals or groups (or involve a mix of both) depending on the resources available. They can be provided by primary care teams and public, private or community organisations with expertise in dietary advice, weight management and physical activity.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
High risk of type 2 diabetes
High risk is defined as a fasting plasma glucose level of 5.5–6.9 mmol/litre or an HbA1c level of 42–47 mmol/mol (6.0–6.4%). These terms are used instead of specific numerical scores because risk assessment tools have different scoring systems. Examples of risk assessment tools include: Diabetes risk score assessment tool, QDiabetes risk calculator and Leicester practice risk score. Risk can also be assessed using the NHS Health Check.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
Lower thresholds (23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk) should be used for BMI to trigger action to prevent type 2 diabetes among Asian (South Asian and Chinese) populations compared to those used for the general population.

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may find it difficult to engage with services. Intensive lifestyle change programmes need to be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Cardiac rehabilitation

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are given a choice of times and settings for the sessions and are followed up if they do not attend.

Rationale

Cardiac rehabilitation programmes improve clinical outcomes for people who have had a cardiac event. However, uptake among people from black, Asian and other ethnic minority groups is lower than in the general population. Providing programmes that are culturally appropriate and sensitive, at settings and times that are convenient can increase uptake. Following up people who do not attend allows for a discussion about potential barriers to attendance and how to overcome them. It also gives the opportunity to motivate people to start or to continue with the programme.

Quality measures

Structure
a) Evidence of local arrangements to discuss any factors that might stop people from black, Asian or other minority ethnic groups from attending a cardiac rehabilitation programme, before they receive a referral.
Data source: Local data collection, for example, from service level agreements.
b) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups in a variety of settings including at home, in the community or in a hospital.
Data source: Local data collection, for example, from service level agreements.
c) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups at a choice of times, for example, sessions outside working hours.
Data source: Local data collection, for example, from service level agreements.
Process
a) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who are offered sessions in a variety of settings including home, the community or a hospital.
Numerator – the number in the denominator offered sessions in a variety of settings including home, the community or a hospital.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme.
Data source: Local data collection, for example, from patient records.
b) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme.
Data source: Local data collection, for example, from patient records.
c) Proportion of people from black, Asian and other minority ethnic groups who missed their cardiac rehabilitation appointment who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups participating in a cardiac rehabilitation programme who missed their appointment.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rate of uptake of cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
b) Rates of adherence to cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed cardiac rehabilitation programmes.
Data source: Local data collection, for example, surveys carried out with people referred to cardiac rehabilitation.

What the quality statement means for different audiences

Service providers (secondary and tertiary care services) ensure they provide individualised support for people from black, Asian and other minority ethnic groups to attend and continue with cardiac rehabilitation programmes. This may include working on overcoming barriers with people who are not willing to engage with services due to poor past experiences or ensuring that the programmes are run on different days, at different times and at venues that are culturally appropriate and convenient. Providers also ensure that a varied range of acceptable and culturally sensitive exercise is available, and people are followed up to continue with the programme.
Healthcare professionals (such as cardiologists and cardiac nurses) identify barriers to attending a cardiac rehabilitation programme and offer individualised support to people from black, Asian and other minority ethnic groups. They offer cardiac rehabilitation programmes on different days, at different times and venues (such as community centres or places of worship) and ensure that they are culturally appropriate and suitable. Healthcare professionals also follow-up people to motivate them to continue with the programme or understand the obstacles that may prevent people from using the service.
Commissioners (clinical commissioning groups) commission cardiac rehabilitation services that have the capacity and expertise to provide people from black, Asian and other minority ethnic groups with programmes that are suitable, acceptable and culturally appropriate. They also ensure that the services support people from black, Asian and other minority ethnic groups to attend and adhere to the programme by addressing the barriers to participation.
People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are supported to attend and keep going to the sessions. This might mean that sessions are available at venues and times convenient to the person or that the sessions are acceptable to them culturally, for example, single sex or with bilingual staff.

Source guidance

Definitions of terms used in this quality statement

Cardiac rehabilitation
A coordinated and structured programme designed to remove or reduce the underlying causes of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that people can, by their own efforts, continue to play a full part in their community and through improved health behaviour, slow or reverse progression of the disease. Cardiac rehabilitation should consist of a multidisciplinary, integrated approach delivering care in lifestyle risk factor management, psychosocial health, medical risk factor management and the optimal use of cardioprotective therapies, underpinned by psychologically informed methods of health behaviour change and education.
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components.
[NICE’s guideline on myocardial infarction, full guideline and recommendations 1.1.1 and 1.1.19]

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may find it difficult to engage with services. Also, some traditions and religious practices may stop people from accessing services on certain days or certain times of the day. Behaviour change programmes need to acknowledge those differences, be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Support for people with mental health problems

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups can access mental health services in a variety of community-based settings.

Rationale

People from black, Asian and other minority ethnic groups are less likely to access mental health treatment than the general population. Mental health illness can be associated with a considerable stigma among people from black, Asian and other minority ethnic groups. Some people may find community-based services, such as a person’s home or other residential settings, community centres and social centres, more appealing, accessible and culturally appropriate than traditional healthcare services. To help combat the stigma and encourage people with mental health problems to access support early, the services need to be visible, accessible and responsive to the needs of the local population.

Quality measures

Structure
a) Evidence of local arrangements to improve access to mental health services for people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, from local commissioning plans.
b) Evidence of local arrangements to ensure that mental health services are provided in a variety of settings that people from black, Asian and other minority ethnic groups can choose from.
Data source: Local data collection, for example, from service level agreements.
Process
Proportion of people from black, Asian and other minority ethnic groups accessing mental health services who are offered support in community-based settings.
Numerator – the number in the denominator offered support in community-based settings.
Denominator – the number of people from black, Asian and other minority ethnic groups accessing mental health services.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rates of uptake of mental health services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection for example, from GP records.
b) Proportion of people from black, Asian and other minority ethnic groups who complete treatment from mental health services.
Data source: Local data collection for example, from GP records.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed mental health services.
Data source: Local data collection, for example, surveys carried out with people referred to mental health services.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services, mental health services and independent providers) collaborate with local communities and people from black, Asian and other minority ethnic groups, healthcare professionals and commissioners to develop local care pathways that promote mental health services tailored to the needs of the local population. They ensure that services are provided in settings accessible and acceptable to people from black, Asian and other minority ethnic groups with mental health problems.
Healthcare professionals (such as GPs, psychiatrists, mental health nurses) offer people from black, Asian and other minority ethnic groups different options for where they can access mental health support to ensure they can choose acceptable and culturally appropriate services. They also collaborate with service providers, commissioners, communities and people from black, Asian and other minority ethnic groups to develop local care pathways that promote mental health services tailored to the needs of the local population.
Commissioners (such as clinical commissioning groups and local authorities) collaborate with local communities, people from black, Asian and other minority ethnic groups, healthcare professionals and service providers to develop local care pathways tailored to the needs of the local population. They ensure that mental health services are provided in a variety of settings and a range of support is available to facilitate access and uptake of services among people from black, Asian and other minority ethnic groups.
People from black, Asian and other minority ethnic groups are given a choice of places to access mental health support. Locations may include their own home, a community or social centre, a GP practice or other local health clinic.

Source guidance

Common mental health problems: identification and pathways to care (2011) NICE guideline CG123, recommendation 1.1.1.7

Definitions of terms used in this quality statement

Community-based settings
Community-based settings include the person's home or other residential settings, community centres and social centres.
[NICE’s guideline on common mental health problems, recommendation 1.1.1.7]

Equality and diversity considerations

Stigma attached to mental health problems among people from the black, Asian and other minority ethnic groups and fear of being sectioned or having children taken away by social services may stop people from accessing mental health support early. To ensure they are culturally appropriate and tailored to the diverse needs of the local population, members of the community should be involved in designing and reviewing the services as well as represented in peer and lay roles to ensure good links into the community.

Physical health checks for people with serious mental illness

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.

Rationale

Life expectancy for adults with a serious mental illness is significantly lower than for people in the general population. People from some black, Asian and other minority ethnic groups are at an increased risk of cardiovascular disease and type 2 diabetes and these conditions can be exacerbated by the use of antipsychotics. An annual health check helps to pick up on early signs of physical health conditions and enables action to be taken to prevent worsening health.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
b) Evidence of local primary and secondary care services working together to monitor and address the physical health needs of people affected by serious mental illness as part of the Rethink Mental Health Integrated Physical Health Pathway.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
Process
Proportion of people from black, Asian and other minority ethnic groups with a serious mental illness who have had a physical health assessment within the past 12 months.
Numerator – the number in the denominator who have had a physical health assessment within the past 12 months.
Denominator – the number of people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
Outcome
a) Premature mortality rates among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
b) Prevalence of type 2 diabetes among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).

What the quality statement means for different audiences

Service providers (such as GPs or mental health services) have systems in place to ensure that physical health assessments are carried out at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. The results are shared (under shared care arrangements) when the service user is in the care of both primary and secondary services. Service providers may involve people in peer and lay roles to support raising awareness of the increased risks and importance of physical health checks among people from black, Asian and other ethnic minority groups with a serious mental illness.
Healthcare professionals (such as GPs or nurses) carry out physical health assessments at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. They share the results (under shared care arrangements) when the service user is in the care of both primary and secondary services. They also highlight the increased risks and importance of physical health checks to people from black, Asian and other ethnic minority groups with a serious mental illness.
Commissioners (such as NHS England local area teams) ensure that they commission services that can demonstrate they are carrying out physical health assessments at least annually in people from black, Asian and other minority ethnic groups with a serious mental illness, and include this requirement in continuous training programmes. They also ensure that shared care arrangements are in place when the service user is in the care of both primary and secondary services, to ensure that the results of assessments are shared.
People from black, Asian and other minority ethnic groups with serious mental health problems have regular health checks (at least once a year). This is to check for problems that are common in people being treated for a serious mental illness, such as weight gain, diabetes, and heart, lung and breathing problems. The results are shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Serious mental illness
Schizophrenia, bipolar affective disorder and other psychoses.
Physical health assessment
A comprehensive health check focused on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease. The annual check should include:
  • weight or BMI, diet, nutritional status and level of physical activity
  • cardiovascular status, including pulse and blood pressure
  • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
  • liver function
  • renal and thyroid function, and calcium levels, for people taking long-term lithium.
[Adapted from NICE’s guideline on bipolar disorder, recommendations 1.2.11 and 1.2.12]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

angiotensin-converting enzyme
angiotensin II receptor blocker
angiotensin II receptor blockers
beats per minute
estimated glomerular filtration rate
usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, and characterised by normal or preserved left ventricular ejection fraction with evidence of diastolic dysfunction
mineralocorticoid receptor antagonist; antagonises the action of aldosterone at mineralocorticoid receptors
mineralocorticoid receptor antagonists; antagonise the action of aldosterone at mineralocorticoid receptors
N-terminal pro-B-type natriuretic peptide
New York Heart Association

Paths in this pathway

Pathway created: May 2011 Last updated: September 2018

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