Leeds wanted to ensure that their cardiac rehabilitation services took account of the needs of BME service users at higher risk of poor health outcomes, in line with national commissioning standards. A lack of ethnicity data meant that local patterns of service delivery and outcomes for diverse ethnic groups could not be identified. The service redesign incorporated an incremental process for improving local data linked to key performance indicators; this helped refocus resources to identify and address service user needs.
As early as 1997, government research suggested that inequalities in life expectancy were resulting from certain ethnic groups not benefiting from cardiac rehabilitation services. Cultural and linguistic barriers were identified as a major contributor, and since then, many reports and studies have confirmed these higher rates of death and suggested that services need to be redesigned to ensure they are accessible to a wide variety of cultures.
Staff at NHS Leeds wished to take account of national guidance on ethnicity and underuse of cardiac rehabilitation services. To do this, they needed to work with a number of different partners involved in cardiac rehabilitation services. They put together a multidisciplinary redesign team including the Commissioning Manager for Long Term Conditions, the Cardiac Rehabilitation Service Manager, a Consultant in Public Health and a GP with special interest in coronary heart disease (CHD). Including clinicians in the team was important not just for gaining insights into how services were currently delivered, but also in making sure that findings and outputs would be useful to medical staff.
Building on national and local data
A local Health Needs Assessment was conducted to provide more detail on the issues highlighted from the national research at a local level. This showed higher mortality and morbidity from CHD and lower access to services such as vascular checks in the more deprived areas of Leeds. Deprivation disproportionately affected service users from BME backgrounds but local ethnicity data about patients with CHD was very limited. National data on ethnicity and coronary heart disease was used to fill the local evidence gaps.
The new specifications for cardiac rehabilitation services included a target for collection of ethnicity data that could be routinely monitored. This was an incremental approach to ethnic data monitoring; using what evidence is available, and demonstrating a need to collect more data. In the same way, an incremental approach could be used to address gaps in other coronary heart disease data which can be addressed through regular audit activity, building the evidence available to plan for improved services in the future.
A separate group to redesign the heart failure pathway has also picked up on these data issues and is promoting better ethnic monitoring by GP practices. Increased awareness about national policy and the importance in considering ethnicity in specific clinical outcomes were important in influencing the approach of the heart failure group.
Work with what is available
The team unsuccessfully tried to obtain additional resources to support the service redesign. Despite this existing resources were prioritised to appoint two cardiac nurses with a specific remit to engage with higher risk BME service users and relevant voluntary organisations. Although these posts are new, there are now dedicated resources deployed on-the-ground to increase use of cardiac rehabilitation services.
Training for the whole staff team following the new appointments provided an opportunity for cardiac rehabilitation nurses to discuss issues of concern, strategies for better engagement and effective ways of working with the BME groups in question. This illustrates how attention in one area can ‘snowball’, and have knock-on benefits to a wide number of staff, who now better understand the need for culturally appropriate redesign, and are all engaged in improving equality of the service.
A strong team improves sustainability
The redesign team members acted as champions for reducing ethnic health inequalities in a context where the focus had historically been on overall clinical outcomes and generic service pathways. However, their progress was hindered by a change in the project management at a late stage of the redesign process. In situations where innovations are being lead by one person, this can have a serious impact, but in a team there is greater momentum, and knowledge is easier to retain. There was a steep learning curve for the new Commissioning Manager who took over this role, but the new manager’s enthusiasm for the work helped the team to overcome the delay and regain momentum.