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A SURVEY OF CARDIAC REHABILITATION IN ENGLAND: CURRENT PROVISION AND OPPORTUNITIES FOR CHANGE THE EXECUTIVE SUMMARY OF A RESEARCH PROJECT FUNDED BY THE CORONARY PREVENTION GROUP Samantha Breen Manchester Royal Infirmary and Buckinghamshire Chilterns University College David Brodie Buckinghamshire Chilterns University College Hugh Bethell Basingstoke and Alton Cardiac Rehabilitation Centre Abstract Introduction Cardiac rehabilitation (CR) is an effective intervention for patients recovering from acute cardiac illness or heart operations. One of the goals of the National Service Framework for Coronary Heart Disease is that 85% of eligible patients be offered CR. However currently only about 30% of eligible patients receive this treatment. The purpose of this survey was to examine in detail a selection of CR units in England - to measure how well they were meeting the NSF targets and following current guidelines, and to identify areas of good practice and shortcomings. From the findings it is intended to make recommendations for producing improvements in CR in England. Methods Twenty eight CR units were selected - one from each Strategic Health Authority in England. Questionnaires were sent to the CR Coordinator, the Coronary Care Unit Nurse Manager, the Primary Care Trust CHD Lead and the Director of Public Health for each Unit. The questionnaires were followed by visits to the CR coordinators and telephone interviews with the other personnel. Results • Only 54% held their own budgets which varied from £32K to £370 K (mean £288/pt). • 25% had dedicated, purpose-built facilities. 47% had facilities which were inadequate for exercise sessions and 61% had facilities which were inadequate for education. • Nurses and physiotherapists were well represented on the CR staff but psychologists were members of the team in just 32% of the programmes. • Doctor support was considered essential by all services but only two services had doctors as core members of the CR team. • The mean number of staff was 3.9 wte per 500 patients which is 63% of the recommended level of staffing. • 14% of services could not offer services to angioplasty patients and only 25% could include heart failure patients. • Only 25% of services had introduced integrated care pathways. • 29% of services did not offer functional assessment before the exercise programme and 79% failed to offer the minimum recommended number of exercise sessions. • 54% failed to offer adequate access to long-term rehabilitation. • 32% did not have computer-based data recording systems and there was widespread disagreement about who was responsible for collecting long-term audit data following CR. • Just one service had met the NSF milestone for a 12 month audit. • On average, 30% of NSF recommendations and current CR guidelines were not being met. Recommendations These include: policy, strategies, identifiable budgets, adequate resources, responsibility for following guidelines, working practices, data collection and audit, optimising patient needs, communication at all levels, improving access and the inclusion of CR in the hospital “star” rating. Introduction Coronary heart disease (CHD) is the most common cause of death in the United Kingdom; one in four men and one in six women will die as a result of the disease. Exercise-based cardiac rehabilitation (CR) is a multifactorial intervention which is known to improve the health and longevity of people with CHD. The Cochrane review in 2004 demonstrated a 20% reduction in all cause mortality and a 26% reduction in cardiac mortality over three years among post infarct patients included in CR programmes. Over the past 20 years there has been a rapid expansion in the number of CR centres in the UK - by the year 2000 all hospitals which treat infarct patients had access to CR. However the effectiveness of CR services in the UK has been questioned by several recent studies: 1 A SURVEY OF CARDIAC REHABILITATION IN ENGLAND • Only approximately 65% of coronary artery bypass (CABG) patients, 25% of acute myocardial infarction (AMI) patients and 10% of percutaneous transluminal coronary angioplasty (PTCA) patients enter CR programmes. • Many CR centres have inadequate funding and some have no identified budget.[4,5] • Many CR centres fail to follow accepted guidelines. • There is poor record keeping. Many cardiac rehabilitation programmes do not collect data on patient throughput and few collect data on the long-term health of participants. In 2000, the National Service Framework (NSF) for CHD was published. Chapter Seven, Standard Twelve, identified clear standards for cardiac rehabilitation, challenging health services to address existing problems regarding the quality, content and access to their cardiac rehabilitation services. In 2002, the Scottish Intercollegiate Guideline Network (SIGN) published a clinical evidence based guideline for cardiac rehabilitation, making recommendations for best practice. The British Association for Cardiac Rehabilitation (BACR) adopted this in 2003. This provided the context for the Coronary Prevention Group (CPG) to commission a study of the cardiac rehabilitation services in England, examining in detail a sample of English CR programmes. This aimed to: • establish how well the requirements set out in Chapter 7 of the NSF for CHD were being met. • assess the extent to which the recommendations of the SIGN Guideline 57 are being followed. • identify areas of good practice which could be recommended to other programmes. • identify shortcomings which could be addressed to improve CR generally. • make recommendations to help to improve the provision and effectiveness of CR in this country. Method One CR service from each of the 28 Strategic Health Authorities in England was randomly selected for inclusion in the study. This represents an 11% sample of the total 260 centres in England. Randomisation was by applying computer-generated random number tables to the available centres in each strategic health authority and selecting one from each authority. Questionnaires were designed to gain information from the key personnel providing cardiac rehabilitation services: • Cardiac rehabilitation co-ordinator. This questionnaire was designed to collect quantitative data, examining in detail the content of all four phases of the CR programme. This was by far the largest questionnaire and sought information on team members, protocols, funding, patients accessing the service, programme content, methods of recording patients’ details and arrangements for follow-up. • Coronary care unit (CCU) nurse manager. This questionnaire included questions relating particularly to the content of the Phase I in- patient process. • The nominated CHD lead and the Director of Public Health (DPH) of the trust in which the programme is based. The CHD lead and DPH questionnaires sought the perspective of managers and focused on the responsibilities for the implementation of the NSF and whether the milestones and goals of the NSF had been achieved. All the questionnaires included a SWOT analysis to seek opinions on the strengths, weaknesses, opportunities and threats for each service. The questionnaires were supported by a visit to the selected key personnel to carry out semi-structured interviews. Where it was impossible to arrange face-to-face interviews, telephone interviews were used for some of the CCU nurse managers, CHD leads and DPHs. The intentions of the visit were: • to complete and verify the quantitative and qualitative data from the programmes. • to observe the cardiac rehabilitation programme in action to gain a greater insight into the content. A SURVEY OF CARDIAC REHABILITATION IN ENGLAND 2 Results Service provision Location of CR services • 12 services (43%) were part of an integrated service (primary care, secondary care and leisure services). • 22 (78%) were in district general hospitals; 3 in stand-alone tertiary services; and 3 in community services. Budget • Only 54% held their own budgets (range £32 K to £370 K, mean £172 K per annum). • For these services the mean expenditure was £288 per person per annum. Facilities • 7 (25%) had dedicated, purpose-built facilities. • Of the remaining, 15 (53%) considered their facilities adequate for exercise classes, 11 (39%) for education and 9 (32%) for one-to-one interventions. • Lack of facilities and space was cited as the main service weakness by 12 (43%). Timing of entry to Phase 3 CR • All but one service had a rolling programme of entry. • Almost all CABG patients started phase 3 CR at 6–8 weeks. • In 20 (71%) centres, acute myocardial infarction patients started CR 4-6 weeks post event and in 7 (25%) before 4 weeks. In one centre, patients waited 3-9 months. • In 9 (32%) centres, angioplasty patients started at two weeks or less and in 13 (46%) at 4- 6 weeks. In one centre, angioplasty patients waited 3-9 months. • Reasons for delay included: referral from tertiary services (32%), waiting list (32%), waiting for results of exercise tolerance tests (18%), waiting for angiography (14%). Staff • 24 centres were co-ordinated by a senior nurse. • 17 (61%) of service co-ordinators were responsible for phases 1-3; 7 (25%) for phases 1 and 3 and two co-ordinators were responsible for all four phases. Team membership Percentage of Centres Types of CR Staff Figure 1 Core Team Members • Every service had a nurse and most employed a physiotherapist and dietician. • There was evidence of multi-tasking and role extension in the core team. • Most services (96%) had multi-professional teams of greater than 5, but the extent of the contribution varied with many seconded to provide sessional work. 3 A SURVEY OF CARDIAC REHABILITATION IN ENGLAND • Support of a doctor was considered essential by all, but only two services had doctors as core members of the team. • Only 6 services (21%) reached the SIGN guidelines of 6.2 whole time equivalents (wte) per 500 patients. • The mean staff wte was 3.9 which represents a shortfall of 2.3 wte from the recommendations of the SIGN guideline. Staff or skill shortages • Co-ordinators considered lack of psychologists to be their greatest deficiency (57%), followed by physiotherapists (43%), counsellors (36%) and occupational therapists (29%). Cover, retention and turnover • In 15 (54%) services, staff members covered each other for holiday and sickness absence. Five (18%) services had no cover options. • Nine (32%) co-ordinators had vacant positions within their team and 6 (21%) had recruitment and retention difficulties. Training and professional development • 14 (50%) services depended on finance from training budgets within their trust; 9 (32%) used monies from the CR budget and 5 (18%) sought funds from elsewhere such as drug companies. • Regular in-service training programmes within the multi-disciplinary team were the norm in 10 (36%) of the services. Percentage of Programmes Category of CAD Figure 2 Category of Patients Offered Cardiac Rehabilitation • All services offered CR to post AMI and post CABG patients. • 24 (86%) offered CR to patients following angioplasty. • All services used troponins to diagnose AMI. • Three (10%) had separate programmes for AMI and revascularisation patients. • A range of troponin levels (< 0.03 - > 0.2) was considered diagnostic. • 16 (57%) services offered CR to transplant patients, 7 (25%) to heart failure patients and 6 (21%) to angina patients. • 10 (36%) services offered CR to implantable defibrillator patients (ICD) but in 4 cases only if they were post- infarct or post CABG. Thus 6 (21%) programmes treated patients with a primary diagnosis of ICD. • Most coordinators did not know the number of infarct or revascularisation patients in their catchment areas, so it was not possible to calculate the percentage of eligible patients who were recruited into the CR programme. Improving access • No services discriminated against particular patient groups. • One group had a parallel Turkish CR programme. • 18 (64%) offered their patients assistance with travel expenses and 5 (18%) were able to do so from their cardiac rehabilitation budget. Most, however, relied on the Trust’s reimbursement scheme for patients on income support. • Some services had developed access initiatives (e.g. free transport – 8, interpreter – 9, video for literacy – 11) but the majority could not address these needs. A SURVEY OF CARDIAC REHABILITATION IN ENGLAND 4 Results Programme content Phase 1 (in hospital) • All services had put in place a workable protocol for active identification and recruitment of eligible patients. The methods used included training ward staff to refer patients through identified channels, daily examination of biochemistry results, close liaison with acute chest pain nurses and active trawling of wards on a daily basis to seek out potential recruits. • 50% actively involved family and carers in patient intervention. • Locally produced information was produced by 22 (79%) of the services, with 6 (21%) using BHF booklets. • Only 7 (25%) of the services had introduced integrated care pathways. • Only two services used the HAD scale and 6 (21%) provided in-service exercise tolerance tests. Phase 2 (following discharge from hospital) • Telephone contact to offer support and advice was made by 24 (80%) of the services. • Home visits were provided by 16 (57%). • The heart manual was used by 10 (36%) of the services. • Two programmes did not offer phase 2 intervention. Phase 3 (the formal, supervised programme) • Most physical conditioning programmes used a group aerobic circuit (96%). • All services calculated heart rate training thresholds. • However, functional assessment was not offered by 8 (29%) of the programmes prior to exercise. • Risk stratification was undertaken by 23 (82%) of the services. • All staff to patient ratios at exercise sessions were within NSF or SIGN guidelines • Defibrillators were available during every session. • Half the programmes had staff trained in advanced life support, and the remainder had staff trained in immediate life support. • Only 6 (21%) services offered 16 or more exercise sessions, the minimum recommended by the SIGN guideline. Percentage of Programmes Number of Exercise Sessions Figure 3 Total Number of Exercise Sessions (recommended minimum=16) • Most education was offered through group talks (93%). • The topics of how the heart works, risk factors, benefits and effects of exercise, medication, diet, relaxation and lifestyle were common to all. • The HAD scale was used by 24 (86%) of the programmes at entry to Phase 3 and 22 centres repeated it if appropriate at exit. • Stress management was offered by 22 (79%) of the centres. • Individual counselling sessions were available in 19 (68%) of the services. Most were by referral, often with long waiting lists. • Relaxation techniques were only offered beyond the educational classes by 8 (29%) of the programmes. Phase 4 (long-term exercise and risk factor monitoring) • Access to Phase 4 was inadequate in 15 (54%) of the programmes. 5 A SURVEY OF CARDIAC REHABILITATION IN ENGLAND Record keeping • Common areas of data collection included medication, smoking habits, blood pressure, cholesterol, body mass index, physical activity, symptoms, anxiety and depression scores. • This information was communicated to primary care using discharge letters, highlighting areas needing further action. • Half of the services used an ‘in house’ database, with 9 (32%) using a paper-based system and the others using the York dataset (2), CalmHeart (1), Tomcat (1) and the original BHF system (1) – see Figure 4. Percentage of Programmes Data Collection Options Figure 4 Methods of Collecting Patient Data Meeting NSF goal and milestones NSF Goal a) that more than 85% of people discharged from hospital with a primary diagnosis of AMI or after coronary revascularisation are offered cardiac rehabilitation b) that at one year at least 50% of people are non-smokers, exercise regularly and have a BMI<30kg/m2 • 26 (93%) CR teams reported that they believed that 85% of eligible patients had been offered CR following AMI or coronary revascularisation. There were no figures available to verify this belief. Milestone 1 “By October 2000, every hospital should have: An effective means for setting hospital-wide clinical standards for common conditions. A systematic approach to determining whether agreed clinical standards are being met”. • There was no evidence of hospital-wide clinical standards for managing CHD. Even if available, the typical standard of record-keeping would make it impossible to evaluate. Milestone 2 “By April 2001, every hospital should have: An agreed hospital-wide protocol for the identification, assessment and management of people who are likely to benefit from cardiac rehabilitation.” • This was achieved throughout the sample surveyed. Co-ordinators have ensured that appropriate systems have been introduced. Milestone 3 “By April 2002, every hospital should have: Clinical audit data no more than 12 months old which describe: number and % of patients discharged from hospital after coronary revascularisation or with a primary diagnosis of AMI with documentation of arrangements for CR in discharge communication to GP. total number and % of those recruited to CR who, one year after discharge, report: 1) regular physical activity of at least 30 minutes duration on average 5 times a week 2) not smoking 3) BMI < 30 kg/m2” A SURVEY OF CARDIAC REHABILITATION IN ENGLAND 6 Results • Only one (4%) service had been able to achieve the 12-month audit from Milestone 3. They had achieved this by calling the patients back to attend a nurse-led 12-month follow-up clinic. • There was widespread disagreement about who was responsible for this audit. Co-ordinators thought it was either their own responsibility (18%), that of the local implementation team (18%), both (7%) or the responsibility of the DPH. • Eight (14%) services had attempted to facilitate this audit by sending to the primary care teams details of patients due for 12-month follow-up. None had received any communication to confirm whether or not the targets had been met. • Two (7%) services stated that they did not have the means to establish whether this had been accomplished. • Half of the co-ordinators did not know who was responsible for implementing standard 12. NSF recommendations Total NSF Recommendations Recommendations Number of NSF Achieved Ranking of CR Programmes visited Figure 5 Implementation of NSF • Twenty-five NSF recommendations were identified, with an average of 70% (range 52-88%) of these having been achieved (see Figure 5). • Those with a database or being part of a district-wide programme appeared the most successful. SIGN Guidelines Guidlines Achieved Total SIGN Guideline Number of Sign Recommendations Ranking of CR Programmes visited Figure 6 Implementation of SIGN Guideline • Twenty-one SIGN guidelines were identified, with an average of 68% (range 48 – 81%) having been achieved (see Figure 6). 7 A SURVEY OF CARDIAC REHABILITATION IN ENGLAND Opinions Opinions of CR Co-ordinators (N = 28) • Strengths of the CR programmes included the multi-disciplinary team (57%), followed by good communication between primary and secondary care (46%), budget (29%), district-wide programme (21%), doctor support (18%), flexible menu-driven programme (18%), dedicated facilities (18%), and a shared multi-disciplinary team office (14%). • Weaknesses identified included: lack of funding (57%), lack of dedicated facilities (43%), poor staffing (32%) and the inability to include all patients with CHD (28%). • Opportunities reported included a wish to include other CHD patients in the service and improving access by the development of Phase 4 (18%), offering "prehabilitation" (14%), moving services into community locations (14%), and involving other agencies such as leisure services (7%). The opportunity for a database to conduct clinical audit and monitor service activity was acknowledged by a third of services. • Reported threats to the service were similar to the major weaknesses reported: financial (54%), staffing (36%) and facilities (18%). Opinions of CCU Nurse Managers (N = 28) • The CCU nurse manager questionnaires confirmed the variation in the cardiology practices. • With the exception of two Coronary Care Units, all were reliant on the cardiac rehabilitation team to administer the expected Phase 1 protocols and only 6 (21%) offered their patients discharge follow-up support in addition to that offered by the CR service. • Troponin levels for AMI diagnosis and type of consultants who managed the care of MI patients varied considerably. • Of the 26 hospitals that had a Coronary Care Unit, only 68% routinely cared for the majority of MI patients on CCU, the remainder were managed between cardiology and general medical wards. • On average only 57% (range 13% to 100%) of the AMI patients admitted to CCU were seen by a cardiologist. • The overwhelming opinion of CCU nurse managers was that cardiac rehabilitation services were failing to address the needs of all patients with CHD. Fifty-seven percent stated that this was a weakness and 50% stated that it was an area of opportunity for service expansion. Opinions of the CHD Leads (N = 20) • Over half of the CHD leads for the trust (55%) felt that the dedication of the cardiac rehabilitation team was a positive strength, followed by communication links between primary and secondary care (27%). • Weaknesses were perceived as waiting lists, lack of services in the community and inadequate staffing in equal numbers (36%). • The most commonly cited opportunities were to allow all CHD patients to access cardiac rehabilitation (45%), to develop links with leisure services (18%) and to gain proper recognition (18%). • The CHD leads perceived few threats to the CR service, although some realised inadequate funding (27%) and staffing (18%) would potentially cause difficulties. • Eleven (55%) of CHD leads were unable to supply figures of MI and revascularisation procedures for their cardiac rehabilitation catchment population, suggesting either an inability to collect or access available data. • There was a major discrepancy between the CHD lead and the CR co-ordinator as to who was responsible for ensuring the implementation of the NSF. • The CHD leads also gave different figures for whether milestones had been achieved. Despite all co- ordinators reporting that the NSF Goal (a) had been achieved, only 90% of CHD leads stated that this was the case. • Only one CR service stated that they had systems in place to collect 12-month data (7%), yet 18% of CHD leads reported that this had been achieved in their trust. Opinions of the Directors of Public Health (DPH) (N = 18) • The dedication of the multi-disciplinary team was overwhelmingly the greatest strength of the CR programme in the eyes of the DPH for the Trust (67%). This was followed by good facilities (33%), offering a range of services (27%) and including all four phases (27%). • The DPHs identified that the inability to include all coronary heart disease patients in CR was the greatest service weakness (47%). • The DPHs most commonly considered that expansion of services to include angina and heart failure patients (55%), followed by the restructuring of services to move CR into the community (33%) were the major opportunities for the cardiac rehabilitation services. • 53% thought that funding issues were the greatest threat to their local cardiac rehabilitation service • 40% of DPHs were unable to give figures for the number of patients eligible for cardiac rehabilitation in their area. • Figures reported for the achievement of the NSF goals were: Goal (a) yes 73%, not known 20%, no 7% Goal (b) yes 27%, not known 40%, no 33% A SURVEY OF CARDIAC REHABILITATION IN ENGLAND 8 Key Findings 1. Only one in five services meet national standards for staff levels, reflecting chronic understaffing affecting both quality of care and staff recruitment and retention. 2. Only one in four services had a fully-integrated “care pathway” through all the phases of cardiac rehabilitation making it difficult to track the progress of patients and provide the statistics needed to verify government standards are being achieved. 3. One in two CHD lead officers could not provide heart attack statistics for their area – a requirement of the NSF. 4. Most programmes failed to provide adequate access to community-based, long-term rehabilitation services (Phase 4) meaning patients have difficulty maintaining the gains made during recuperation with consequent impact on morbidity and mortality. 5. One in three services does not undertake the correct functional assessment needed prior to starting a formal exercise programme. 6. Only two of the 28 services surveyed included doctors as core team members. All cardiac rehabilitation practitioners consider that medical support essential, although the clinicians ultimately responsible for patient management are rarely involved in day-to-day rehabilitation. 7. Only half of the cardiac rehabilitation services hold their own budgets, limiting the ability to make management planning decisions locally. 8. Fewer than 70% of the NSF recommendations and the national adopted guidelines are being achieved, due to limited staffing and resources. This will not change without direct funding to CR services which are desperate to improve their performance standards. 9. Forty percent of Directors of Public Health were unable to supply figures for how many eligible patients received CR in their area, questioning the auditing standards for CHD which affects management decision making. Provisional Recommendations The following provide a basis for discussion at the forthcoming Symposium “Cardiac Rehabilitation: How to do better” on February 3rd 2005. It is anticipated that following the Symposium, these recommendations will be revised and extended for inclusion in the final report. To the Department of Health • Adequate provision of cardiac rehabilitation is included as a qualifying point for the ”star“ system in all hospitals. To Strategic Health Authorities • A clear cardiac rehabilitation policy within the SHA should be established. • Joint strategies with trusts, social and leisure services should be implemented to improve opportunities and access to patients with CHD. To Trusts and Cardiac Networks • Trusts should provide adequate resources to cardiac rehabilitation services through an identifiable budget. • Trusts should look at ways to provide suitable accommodation and facilities. • An identified CHD lead should be appointed who is responsible for ensuring evidence-based practice and that national guidelines are being followed. • The cardiac rehabilitation coordinator should be a member of the local implementation team or equivalent to ensure two-way communication of cardiac rehabilitation activity and policy. • Systems should be established to enable low to moderate risk patients to be treated in the community setting. • Working patterns should be established which permit CR providers to work across all sectors; hospital trust, primary care trusts and leisure centres. 9 A SURVEY OF CARDIAC REHABILITATION IN ENGLAND Provisional Recommendations continued • Adequate IT systems should be installed to improve data collection and audit. Ideally both primary and secondary care should be able to access the information. To Cardiac Rehabilitation Practitioners Every effort should be made: • To improve communication across primary and secondary care boundaries. • To work closely with leisure services to optimise long-term provision of cardiac rehabilitation. • To audit the CR programme against national guidelines and standards to identify any failings and gaps in provision. • To develop flexible approaches to enhance access, participation and adherence. • To communicate service activity to the trust and SHA. • To look at ways to tailor service to individual needs, offering a flexible, menu-driven approach. • To work with the PCT to find a workable solution for collecting the long-term cardiac rehabilitation data, forging links with CHD registers. References 1. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane review). In: Cochrane Library, Issue 4, 2000. Update software. 2. Bethell HJN, Turner SC, Evans J, Rose L. Cardiac rehabilitation in the United Kingdom: How complete is the provision? J Cardiopulm Rehabil 2001;21:111 3. Griebsch I, Brown J, Beswick AD et al. Is provision and funding of cardiac rehabilitation services sufficient for the achievement of the National Service Framework goals? Brit J Cardiol 2004;11:307-9. 4. Bethell HJN, Turner SC, Evans J. Cardiac rehabilitation in the UK 2000 - can the National Service Framework milestones be attained? Brit J Cardiol 2004;11;162-8. 5. Thompson DR, Bowman GS, Kitson AL, de Bono DP, Hopkins A. Cardiac rehabilitation services in England and Wales: a national survey. Int J Cardiol 1997;59:299-304. 6. Lewin RJP, Ingleton R, Newens AJ, Thompson DR. Adherence to cardiac rehabilitation guidelines: a survey of rehabilitation programmes in the United Kingdom. Lancet 1998;316:1354-5. 7. Department of Health. National Service Frameworks. Coronary Heart Disease. Department of Health, London, 2000. 8. Scottish Intercollegiate Guideline Network. 57 Cardiac rehabilitation. A national clinical guideline. Royal College of Physicians, Edinburgh 2002. Acknowledgement Lynette Hodges’ involvement in the production of graphs in this report is appreciated, as is the substantial contribution of all health professionals surveyed in this report. Samantha Breen David Brodie Hugh Bethell On behalf of the Coronary Prevention Group, January 2005 A SURVEY OF CARDIAC REHABILITATION IN ENGLAND 10 The aim of the CPG The CPG aims to promote action on the prevention of CHD. Our mission statement is: 'To help prevent death and disability from coronary heart disease through measures designed to inform, motivate and enable people to adopt healthy lifestyles and to work with the Government, health care workers and others to adopt policies to the same end.' Our objectives are To promote a reduction in smoking, healthier diets, more exercise and a lifestyle conducive to a low risk of CHD and better health. To provide free and accessible information on all aspects of heart disease prevention via the Healthnet website. To provide a forum for health professionals to exchange health promotion information via the Healthpro website. To stimulate debate and discourse between academics and health promotion professionals on matters relating to heart disease by organising scientific meetings. To monitor and comment on the acceptability and effectiveness of Government activities and policies on heart disease.
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