Dr Hasnain Dalal, joint runner up in our Awards, describes his PCTÍs successful strategy to create a seamless cardiac rehabilitation service


The National Service Framework for Coronary Heart Disease advocates the integration of hospital and primary care cardiac rehabilitation services.

The Carrick scheme of ïseamlessÍ cardiac rehabilitation was developed in 1999 after a 2-year pilot using the Heart Manual in primary care. Before 1997 patients had to travel to hospital to receive cardiac rehabilitation. Long term follow up of patients surviving a myocardial infarction was patchy. Few practices had validated CHD registers and none had CHD trained nurses to provide systematic care through nurse-led clinics.

Implementing guidance

To implement the National Service Framework for CHDÍs guidance for cardiac rehabilitation and secondary prevention, we took the following steps:

  • Set out our aim and objectives based on:
    • the findings of a conference organised by the Cornwall and Isles of Scilly Health Authority;
    • the NSF for CHD Emerging Findings Report;1
    • and-two British Medical Journal editorials calling for better integration of primary and secondary care in the provision of cardiac rehabilitation.2,3
  • Obtained funding for the project.
  • Enlisted support from Carrick PCT for all 13 practices – 63 GPs with a total list size of nearly 100 000.
  • Identified an accredited CHD course for practice nurses.
  • Wrote guidelines and protocols for use in practices and in hospital.

Aim and objectives

Our aim was to offer cardiac rehabilitation and secondary prevention for all patients discharged with a primary diagnosis of acute myocardial infarction. Our objectives were to:

  • Identify and offer rehabilitation to all patients following acute MI.
  • Establish a link between hospital and primary care services.
  • Provide education in CHD and rehabilitation for practice nurses.
  • Encourage long term follow up in primary care.


Initial funding came by way of grants from the British Heart Foundation, Duchy Health Charity and the Cornwall and Isles of Scilly Health Authority, which helped to set up the service.

PCT support

Before the National Service Framework for CHD was published, we secured funding from Carrick PCT for secondary prevention clinics on a par with other chronic disease management payments, such as those for asthma and diabetes.

CHD course

We invited the charity Heart Save from Oxford to come and run their ïMaking it HappenÍ course in Cornwall. Each of the 13 practices sent at least one practice nurse on this 3-day course. Now each practice has a nurse trained to certificate or diploma level in secondary prevention of CHD.

Our practice in Truro has provided training sessions for other practice nurses by allowing them to sit in with our nurse in the weekly CHD clinic.

In May 2000 we invited the Heart Manual trainers to Cornwall to run their course. As a result, eight practice nurses in the PCT are fully trained Heart Manual facilitators.

Guidelines and protocols

We adapted guidelines on running CHD secondary prevention clinics from the Medical Centre, Shipston on Stour, Warwickshire. A version of their guidance is published with the NSF for CHD.

Our liaison nurse developed a protocol for patients seen in hospital. This is based on her experience and the goals stated in the cardiac rehabilitation chapter of the NSF.

Improvement in evidence-based practice

All 13 practices have a CHD chronic disease register and offer structured care, as recommended in the NSF. The practicesÍ CHD nurses attend a twice yearly educational meeting organised by the PCT to provide an update and feedback on their audits.

Table 1 (below) shows the results of an audit of patients discharged with a primary diagnosis of acute myocardial infarction. The first data collection was made at discharge from hospital and the second at 12 months post-discharge. It shows that we have achieved optimal secondary prevention with regard to smoking cessation (80-90% of patients), and a substantial improvement in the percentage of patients with total cholesterol of less than 5mmol/l at one year post-MI (65% compared with 28% at baseline).

Table 1:Secondary prevention data at baseline and at follow-up (n=106)


Baseline n (%) Most recent n (%)




Status not known


33 (31)

71 (67)

2 (2)


11 (10)

84 (80)

11 (10)




Not known


77 (73)

16 (15)



82 (77)

18 (17)

6 (6)

Total cholesterol level

<5.0 mmol/l

>=5.0 mmol/l

Not known


30 (28)

71 (67)

5 (5)


69 (65)

23 (22)

14 (13)

Blood pressure

<140/85 mmHg

>=140/85 mmHg

Not known


73 (69)

18 (17)

15 (14)


71 (67)

27 (25)

8 (8)

We have also met the NSF targets for acute MI survivors at one year of 50% non-smokers and 50% with a body mass index of less than 30kg/m2.

Tangible benefits for patients

The NSF states that more than 85% of patients discharged after MI should be offered cardiac rehabilitation.

In our PCT we identified 359 patients discharged after an MI over 2 years (1999-2001). Over 90% were offered some kind of rehabilitation (Figure 1, below). The most popular option, chosen by 41%, was home-based rehabilitation using the Heart Manual. Nearly a fifth (19%) elected to take the group based classes in hospital. Those patients for whom neither of these options was suitable because of co-morbidity or advanced age (34%) were offered an alternative, tailor-made package.

Figure 1: The three options for cardiac rehabilitation

On discharge from hospital, all patientsÍ details are passed to a named CHD-trained practice nurse.

A recent PCT-wide audit shows an improvement in uptake of secondary prevention medication with over 90% of post-MI patients taking aspirin or other anti-platelet therapy, 74% on statins and 60% on beta-blockers.

In March 2000 the PCT conducted a survey about the service which reflected high levels of satisfaction among patients.

Rolling out the project

NHS Beacon status, awarded to the practice in 1999, has given us the opportunity to disseminate our work widely. The National Heart Foundation of New Zealand has expressed an interest in our work as it has implications for providing rehabilitation in rural communities.

Our strategy for providing rehabilitation and secondary prevention has been recommended by the SouthWest CHD Collaborative for adoption by other PCTs in Cornwall. The scheme is now operating throughout Central Cornwall PCT (formerly Carrick PCT and Restormel PCG) and a similar scheme is running in West of Cornwall PCT.


  1. National Service Framework on Coronary Heart Disease - Emerging Findings Report. November 1998. www.doh.gov.uk/nsf/coronary1.htm
  2. Mayou R. Rehabilitation after heart attack. Br Med J 1996; 313: 1498-9.
  3. de Bono DP. Models of cardiac rehabilitation. Br Med J 1998; 316: 1329-30.


Guidelines in Practice, November 2002, Volume 5(11)
© 2002 MGP Ltd
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