1. South Wales Cardiac Network Cardiac Rehabilitation Advisory Group Meeting Aneurin Bevan Local Health Board Cardiac Rehabilitation Service Suzanne Indge CNS February 2011

2. Our Service Cardiology Directorate Cardiologist Consultant Nurse South Gwent/Newport St Woolos Post MI Surgery Angina North Gwent Nevill Hall Post MI Surgery Angina Heart Failure Caerphilly Post MI Surgery Torfaen/Pontypool County Post MI Surgery Heart failure Manager for Unscheduled Care Director of Nursing

3. Phase 1 Phase 1 provided at Nevill Hall and Caerphilly Miners using Heart Manual for ACS and angina patients. BHF, “An Everyday Guide to Living with Heart Failure” is used for heart failure patients Limited Phase 1 provision in Royal Gwent

4. Phase 2 All patients are contacted via telephone within 7 days of discharge or referral. Occupational Therapist in Nevill Hall carries out home visits if needed predominately for heart failure patients or patients with reduced functional capacity. Nurse led heart failure clinic for review of patients 3-4 weeks post discharge

5. Phase 3 North – 3 programmes per week (8 classes), 1 hospital and 2 community based for heart failure, angina, post MI and surgery South – 6 programmes per week (11 classes), 5 hospital based for heart failure, angina, post MI and surgery, 1 community based for angina, post MI and surgery. Walk programme x2 week in Torfaen

6. Nurse led services Clinic review for patients with coronary artery disease and complex needs Clinic review or home visits for all patients with heart failure, liaison with palliative care

7. Phase 4 North – 22 classes across North Gwent part funded by charitable funds South – 18 classes in Newport area 12 classes in Caerphilly area 17 classes in Torfaen area

8. Limitations to service No heart failure programme in St No angina programme in Caerphilly Miner’s Inequitable staffing and service provision across Aneurin Bevan Health Board

9. North Gwent Team MI/ CABGAnginaHF Nurse Band 71 1 1 Nurse Band 610.81 Physio Sen I Band 60.530.3 Basic Grade (rotation) Band 60.3200.2 Physio tech Band 3/ 40.20.16 Occupational Therapist Band 60.60.05 Dietician Sen I Band 60.1 0.08 Psychotherapist ad hoc0.40.10.05 Pharmacy Band 60.0500 Fitness Instructor band 50.260.20.1 AC III Band 30.470.50.7

10. Caerphilly Team Caerphilly/ Pontypool MI/CABG Caerphilly MI/CABG HF County Nurse Band 700 Nurse Band 61.30.8 Physio Sen I Band 60.5 Basic Grade (rotation) Band 600 Physio tech Band 3/ 40.160.4 Occupational Therapist Band 600 Dietician Sen I Band 600 Psychotherapist ad hoc00 Pharmacy Band 600 Fitness Instructor band 500 AC III Band 30.250

11. South Gwent Team St Woolos MI/ CABGAngina Nurse Band 711 Nurse Band 610 Physio Sen I Band 60.410.56 Basic Grade (rotation) Band 600 Physio tech Band 3/ 400 Occupational Therapist Band 600 Dietician Sen I Band 600.01 Psychotherapist ad hoc00 Pharmacy Band 600 Fitness Instructor band 500 AC III Band 30.140.36

12. Significant Successes Intergrated patient pathway referenced against Peplau nursing model ICD support group set up across Aneurin Bevan Charity partnership across Aneurin Bevan Audit collection across Aneurin Bevan Patient stories in Caerphilly achieved TV coverage Expert opinion on NICE board for angina Chair of AWCRWG

13. Significant Successes Chair of SE Cardiac Network Cardiac Rehab Group Cardiac rehab health professional band 5 job description and specification developed, agenda for change approved and outline for eKSF developed. Now awaiting sign off. Parental diuretic nurse BHF bid successful 2010 BHF heart failure post re-instated in Caerphilly RCBC award (strategic insight programme) 2 programmes in North successfully moved into the community

14. Current Challenges Introduce and sustain Heart Manual across Aneurin Bevan Health Board Commence a heart failure rehabilitation programme in Caerphilly Provide equitable cardiac rehabilitation service across Aneurin Bevan Health Board

15. Anything Else? Keeping the patients at the centre of our service planning, 3 staff to undertake story works training to provide comprehensive patient stories.