Multimorbidity Rehabilitation- The Sustainable Way Forward


Recognising that there is limited funding for “doing more of the same” we looked at how we could increase our cardiac rehabilitation capacity by broadening our scope and expertise to encompass a range of long term conditions that cause a high impact on unscheduled care. We acknowledged that multi-morbidity is becoming increasingly prevalent.

We subsequently developed The Healthy and Active Rehabilitation Programme (HARP) and opened up referrals to include people affected by stroke, cancer, COPD, falls, diabetes, and other long-term conditions.  HARP enabled us to widen our rehabilitation capacity to include cardiac groups which are typically excluded due to resource limitations: angina, arrhythmias and devices.  We designed a programme that would embrace activity, self management and support lifestyle change, across all of these groups.

Thus, the overall aim of this project was to proactively support prevention and self-management in an ageing population with increasing prevalence of chronic multiple morbidities. To help reduce health inequality the project has specifically targeted deprived and rural communities.

Secondary objectives 

  • To develop an evidence base for multimorbidity rehabilitation that would support a new way of working
  • To prove that this new model was sustainable
Potential cost avoidance in 12-month period


This rehabilitation model was designed using a novel, tiered approach. Service users can move between tiers to suit their needs:

Tier 4: Traditional, condition-specific rehabilitation

Tier 3: A new, innovative programme for those struggling to manage multiple conditions

Tier 2: Local leisure services

Tier 1: Third sector community and voluntary groups

Initial evaluation focused predominantly upon Tier 3, and included the following outcomes:

  • Euro-QoL (EQ-5D-5L) questionnaire to evaluate quality of life (QoL)* and cost-effectiveness
  • Visual analogue scales (QoL, fatigue, fitness, physical function and weight management)*
  • Cardiovascular risk factor profiles*
  • Impact upon unscheduled care usage

*[Examined pre- and post- Tier 3]


  • EQ-5D-5L data: 10-30% reductions in number of service users reporting ‘a problem’ within each domain (mobility, self-care, usual activities, pain, anxiety / depression)
  • Visual analogue scales: 20-30% improvement across all measures
  • Cardiovascular risk factor profile: data improvements in all areas of lifestyle behaviour change, equivalent to those obtained from cardiac rehabilitation

Cost and savings

Unscheduled Care Usage: 

In the 12-month period following referral to HARP, there was a significant reduction of 72% in total emergency bed days accrued by those who completed the Tier 3 programme, versus a similar group of age and sex matched multimorbidity referrals.  This translates to a potential cost avoidance of £122,841.


The cost per quality-adjusted life year for delivering Tier 3 was calculated at £29,350 (cost-effectiveness threshold: £30,000) – thus HARP is cost-effective


This project has implications for national spread as a model of care.

The increasing prevalence of multi-morbidity has rendered this ‘the new normal’.  The importance of self-managing chronic conditions should be built into education and practice – from undergraduate student level and continuing in practice as part of ongoing CPD.

Top three learning points

  • Multi-morbidity rehabilitation works and is sustainable.
  • The values of partnership working with the Third sector and embracing volunteer peer support
  • Collaborative health and social care working across the four tiers of HARP presented challenges, none of which were insurmountable.


    Funding acknowledgements

    Thank you to North, East and South Ayrshire Social Care Partnerships who fund us, initially through The Integrated Care Fund.

    Additional notes

    Brian Whittle, South Scotland, Scottish Conservative and Unionist Party met with the team, as he was keen to hear more about HARP.  Brian subsequently lodged the following Scottish Government Motion [Motion S5M-09158] in December 2017:

    Recognising the Importance of NHS Rehab Programmes

    That the Parliament recognises the importance of a rehabilitation pathway in supporting patients with a range of long-term conditions and those recovering from a trauma; understands that clinical guidelines recommend that the NHS provides programmes of pulmonary rehabilitation and cardiac rehab sessions; notes that organisations such as Chest, Heart and Stroke Scotland and the Chartered Society of Physiotherapy are highlighting the importance of community-based physiotherapy and long-term community support in effective rehabilitation; recognises what it sees as the significant impact that community rehabilitation programmes, such as NHS Ayrshire and Arran’s multi-condition rehab pilot, the HARP project, can have on patient outcomes; understands that NHS rehabilitation programmes combine physical activity and physiotherapy with education, advice and support; acknowledges what it considers the considerable physical and mental health benefits of rehab programmes, as well as their ability to reduce hospital admissions, GP appointments and tackle the social isolation often felt by patients; notes the importance of rehabilitation in helping people self-manage their health conditions and maintain their quality of life, and further notes the challenges faced by the NHS in directing resources towards long-term rehabilitation and support.

    Service user perceptions of HARP were published in the following paper:

    Cowie A, McKay JA, Keenan A. Combined Generic-Specialist Multimorbidity Rehabilitation Post Acute Cardiac Event British Journal of Cardiac Nursing 2018; 13(7): 340-47  [abstract link:]