What we expected to do
Angus Cardiac Group is the lead partner in a well-established programme providing physical
activity opportunities for people with a long-term condition in the community. The
BE ACTIVE…live well programme includes circuit, gym, and seated exercise classes, and
encompasses Refer2Exercise (the Angus exercise referral scheme which now also allows
self-referral), and referral from rehabilitation services. In the last year (October 2014 to
September 2015) there were over 27,000 attendances across 8 sites in Angus. A recent
count of individuals over the course of one week showed that there were 383 people
benefiting from the programme.
NHS Tayside currently provides a ‘once a week for 8 weeks’ hospital based education and
activity programme for people who have had a cardiac event. People are then encouraged
to access one of the programme’s community classes. The former’s programme is daytime
only, and the vast majority of the latter’s classes are also during the day. We recognised
that what was currently offered in Angus, i.e. mostly daytime, circuit based classes
(attended by older, retired people) may not be meeting the needs of younger cardiac
patients who go back to work soon after treatment. Could we therefore attract those who
chose not to access, or are unable to access existing cardiac rehabilitation opportunities?
Could we achieve the following outcomes?
1. More people with coronary heart disease (CHD) are accessing physical activity
opportunities in the community
2. People with CHD are better informed about their health condition
3. Exercise instructors have increased knowledge and skills in relation to cardiac
rehabilitation
4. People with CHD feel more supported to manage their health condition
5. People with CHD are better able to self-manage their condition
In order to achieve these outcomes, our activities included:

Developing a flexible referral pathway for accessing community cardiac rehabilitation
(CCR)

Liaising with the cardiac rehabilitation team, GP practices, Angus Council Leisure
Services, participants, and NHS Tayside to facilitate access to physical activity and
education
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
Piloting evening exercise classes in local leisure centres

Piloting new ways of delivering group education classes on a range of topics related
to managing CHD

Providing 1-1 gym inductions and programmes

Providing training and support to community based exercise instructors

Providing 8 initial sessions free of charge within leisure centres for new participants,
to encourage attendance

Promoting the benefits of cardiac rehabilitation within the community
What we actually did
Over the 6 month period from April 2015 to September 2015, we have achieved the
following:

As from the project’s inception, we continued with regular management group meetings
to direct our activities

Our 8 session free pass was given to new participants. 15 passes have been issued in
this last 6 month period. 45 passes have been issued since the project started

In total, 46 people engaged with the project (13 new people in the last 6 months). The
variety of paths taken by these participants is shown appendix 1. This demonstrates the
flexibility in what we offered, and that a person centred approach can be achieved

Exercise instructor study session in May (see appendix 2). This was an opportunity to
follow-up on topics from recent BACPR training courses, to revise some key areas, and
to allow exercise instructors to share ideas

8 exercise instructors attended ACPICR* ‘Principles & Application of Resistance
Training’. This training course was held is response to requests from exercise
instructors and aimed to increase awareness, understanding, and confidence in
prescribing resistance training to participants with cardiovascular disease

As reported previously, we identified that the level 4 course ‘Physical Activity for
Adults with Mental Health Conditions’ was a very relevant and important course for
ensuring our instructors have the knowledge and skills to deal with mental health issues
experienced by some participants. We have supported a further 5 instructors to
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undertake this course

A series of ‘roadshow’ events to engage with health and social care professionals were
held at 6 leisure facilities across Angus. These were informal lunchtime meetings. Each
event featured a class participant discussing their experiences of attending the classes,
provided an opportunity to meet the exercise instructor, and provided information on the
background to the programme and how the referral process works. 32 professionals
attended from a range of disciplines/services, including physiotherapy, mental health,
and social care

A comprehensive review of the overall programme was undertaken. The review
engaged with partners, a wide range of professionals (via the roadshow events
described above), participants, and those who deliver the sessions (exercise instructors
and volunteers). The aim was to assess the effectiveness of the programme and to
identify recommendations arising from this in order to ensure the programme is
sustainable in the future. A summary of the review is included as appendix 3. The full
report is available on request
*Association of Chartered Physiotherapists in Cardiac Rehabilitation
What difference we actually made
Of the 60 people recruited during the project 14 did not engage, meaning we had an uptake
of 77%. The average age of participants was 64 years old (range 20 to 86 years).
Of the 45 people who accepted the ‘8 session free pass’, 53% completed all 8 sessions,
and a further 9% completed 4 or more sessions.
Altogether, 32 people out of the 46 that engaged with the Project returned the ‘Patient
Feedback Questionnaire’. Feedback included:

In response to why participants chose the location and mode of exercise that they
did, ‘company of friends’, and ‘course made me realise value of even moderate
exercise’ were cited

‘Excellent programme- always came out feeling I had a good workout’

‘I am happy and coping with the class exercise I am doing’

I have just heard today that the course I attended is ending because of lack of
attendance. I am really disappointed because the small numbers meant that we got
more personal attention’.
From our quantitative evaluation we can demonstrate that participation in the project has
made a positive difference in a number of ways:

Comparing responses before and after participating in the exercise sessions there
was a marked increase in people’s perceived ability to perform daily activities (the
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response of ‘no difficulty at all’ increased from 40% to 76%)

Overall health was rated ‘excellent’ by 15% before, and by 39% after

Asked to rate how much their health had limited their social activities, 16% said
‘quite a bit’ before, but in the follow-up questionnaire no one gave this response. This
reinforces our belief that the social element of the classes can improve confidence
and ability to socialise

In the pre-questionnaire, 15% said emotional problems had bothered them ‘quite a
bit’. Afterwards this was zero. Those who responded ‘not at all’ or ‘slightly’ increased
from 75% to 89%
We devised a simplified questionnaire to encourage more people to provide feedback (see
appendix 4) which we introduced in this last period of the project. This was given after they
completed all their sessions. Results are shown in appendix 4. Key findings were:

80% felt they were better informed about their health condition (60% ‘somewhat’
& 20% ‘definitely’)

80% felt more supported to manage their health condition (50% ‘somewhat’ and 30%
‘definitely’)

Asked whether they felt better able to self-manage their condition 50% said
‘definitely’ and 40% said ‘somewhat’

75% indicated that they will continue to be physically active
Challenges and changes
It has been more difficult than expected to recruit participants to the project. We know that
there are many more people that could have accessed the exercise & education
opportunities on offer, but who were not referred. It is not clear why more people were not
referred, despite the wide advertising of the project.
It was hoped that the move towards the option of self-referral would facilitate people
attending. Whilst this has helped increase capacity in Primary Care, people still need a
prompt by Health Practitioners to encourage attendance at a physical activity programme.
The Roadshows were held locally and were an opportunity for practice and community staff
to learn more about the referral process and to ask questions if they had any queries.
However, attendance was lower than expected in some areas.
Given more time, we could have explored the reasons for low referral more fully.
The evening classes in one area were not well attended and ceased as they had become
not financially viable. However, the evening class in another area worked better. But even
that class then had to be merged with an existing referral class to ensure its viability.
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Learning for the future
Evening classes were set up to accommodate younger people with cardiac disease who
were still at work.
However, many of the younger people preferred to access the gym themselves or do their
“own thing”. Those who did attend the gym on their own appreciated the opportunity to
have a one-to-one consultation with the Exercise Instructor, and have a programme written
specifically for them. They also had the opportunity to go back to the instructor if there were
specific questions they needed to raise.
It is clear that the culture of concern in exercising people with heart disease is lessening,
and that more people are recognising the importance of physical activity as a healthy
lifestyle choice and tool for self-managing any health condition they may have.
It is also clear that, for some people, exercising in a community setting, with or without the
support of an Exercise Instructor, is a safe and viable option for people with heart disease.
Recruiting participants
Ongoing relationships with GP practices, outpatients, and rehabilitation services will be
crucial to ensure those who could benefit from our community programme are made aware
of it. We still feel that there are a large number of people with CHD in Angus who are yet to
engage. Awareness raising with health professionals, and the community as a whole, must
continue in the future.
Access to community physical activity opportunities for cardiac participants
We want to encourage more people with cardiac conditions to exercise in the community.
This depends on being able to provide exercise opportunities that meet their needs, in terms
of timing, type, and location. Another crucial factor is to have sufficient numbers of well
trained and skilled exercise instructors in order to support community physical activity
opportunities for cardiac, and other long-term conditions.

Timing of class
We had thought that putting on evening classes would attract those who were
working and unable to attend daytime classes. We have had limited success with
these. We set up a Forfar gym class which ran for 7 months. However we were not
successful in recruiting a large enough number of participants to make this
sustainable in the long-term. This was despite regular contact with GP practices in
the area to promote the class, as well as posters being distributed widely in the
community. The evening gym class in Brechin continues to be run. However this has
now been amalgamated with an existing Refer2Exercise class to ensure its ongoing
sustainability. We feel it is important to be able to offer evening classes but our
experience in this project is that we won’t be able to sustain ‘cardiac only’ classes.

Type of classes
Looking at the people who engaged with the project, 61% opted to exercise in a gym
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environment (either in a class or independently). Those who chose a 1-1 gym
programme (30%) had an average age of 58 years old (compared to the overall
average of 64 years). So it is clear that we need to ensure that this option continues
to be offered in the future as this seems the most attractive option to the younger
participant we need to engage with.

Exercise Instructors
Appropriately qualified Exercise Instructors are essential for a successful exercise
programme that caters for people with one or more long-term health condition. In the
present climate of financial constraints, it is important the instructors continue to be
supported and developed to sustain the programme.
It is apparent that participants with health conditions need additional time and
commitment to promote adherence with activity. This is particularly true of those with
a mental health condition, who often do not complete the planned programme of
exercise.
The opportunity for our instructors to undertake training in Mental Health Conditions
was valuable and is proving very useful in understanding and managing the behavior
of participants in the programme. Establishing links with mental health services in
Angus has already generated a study session to support exercise instructors, as well
as highlighting that we can access training such as suicide awareness at no cost.
Developing these links further in the future will help our programme to be even better
at supporting participants with mental health conditions.
How we collected the information
As the project progressed, and we learned what was/was not working, we refined the
evaluation questionnaires that we used. Participants were issued with 2 questionnaires
when they completed all their sessions:

Patient Feedback Questionnaire (which asks about their experience of the
programme). This was included in the September 2014 report

A revised Evaluation Questionnaire which sought evidence on outcomes 2, 4, and
5 above. This is attached as appendix 4
Exercise instructors were asked if their knowledge and skills had improved as a result of
training received (see appendix 5).
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How we spent the money
Details of the expenditure are included below (appendix 6). The actual spend to date (for 24
months of funding), actual 6 month spend, and the overall budget is shown.
We spent 98% of our total funding. We did have a significant underspend to address during
this last 6 month period which we were largely successful in achieving. Our underspend at
the end of the project is £1,925.
Areas that show significant variances from the budget are:
Time: Our overall time costs are lower than the budget due to the delay in our second
CRSN starting, and there being fewer new participants to support than we anticipated. Our
original CRSN left the project in mid-April which also impacted on the budget.
Training: Ensuring exercise instructors are appropriately trained to deal with participants is
essential to the success of the programme. We therefore chose to support 5 instructors to
attend the level 4 course on Mental Health Conditions. 8 instructors attended the
Resistance Training course. This increased our training budget but was seen as a very
good way to address our ongoing underspend. The associated ‘travel & accommodation’
spend was lower than budgeted because these courses were brought to Angus. The budget
had been set on the basis that we’d have instructors attending the BACPR phase IV
instructor course in Glasgow but this was not possible in the timescales.
Promotion: As discussed above, ongoing work to ensure health and social care staff are
aware of what is available in our programme is crucial. We want to ensure that both
referrals, and self- referrals continue and grow in number. Promotion costs were higher than
budgeted for. We purchased promotional material including mugs, caps and shopper bags.
These were used at the roadshow events and other local and national events where we
have the opportunity to promote the work of the project.
Monitoring & Evaluation: We had increased this budget to take into account the ‘review’
that we decided to conduct (which was seen as an opportune way of dealing with the
underspend). However, we successfully completed the review under budget hence the
lower spend on ‘monitoring & evaluation’.
Appendix
Appendix 1: Pathways of beneficiaries accessing community physical activity
Appendix 2: Programme for Exercise Instructor Study Session, May 2015
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Appendix 3: Review summary
Appendix 4: Evaluation questionnaire with results
Appendix 5: Exercise Instructors Training Evaluation Questionnaire
Appendix 6: Budget and expenditure summary
Appendix 1: Pathways of beneficiaries accessing community physical activity
Exercise chosen
Number of
participants
1-1 gym programme
13
Private gym
1
Circuit class
12
Seated exercise
5
Gym class
11
Aqua class
1
1-1 gym programme and circuit class 2
1-1 gym programme and seated class 1
TOTAL
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46
Appendix 6: Budget and expenditure summary
Angus Activity Programme for People with Long Term Conditions
Alliance Funds – 24 Monthly Expenditure Summary to 30 September 2015
ACTUAL
24 Month
SPEND
To 30/09/15
BUDGET
Alliance Funding
£86,780
£86,780
£86,780
£86,780
£21,695
£8,518
£30,213
44036
8110
42255
7305
11347
1810
9481
5857
12528
3325
5495
722
7460
1380
4200
3716
2540
6530
1033
5839
2309
3731
1266
510
2981
2309
1848
£86,780
£84,855
98% Spend
£28,288
94% Spend
£0
£1,925
£1,925
Underspend bfwd from 18 Months to 31/03/15
Time
Travel
Training & Development :
Training
Travel & Accommodation
Equipment
Pilot Courses
Promotion
Monitoring & Evaluation
Administration & Documentation
Underspend for 24 Months to 30/09/15
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6 MONTHS
ACTUAL
SPEND
TO 30/09/15