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 Exercise on Referral, self-referral, and referral from rehabilitation services
(primarily cardiac rehabilitation). In 2014 there were 26,878 attendances across 8 sites in
Angus.
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. These are weekly classes
held during the day in 3 sites.
Recent advances in treatments for cardiac disease have dramatically changed the
traditional cardiac rehabilitation journey. Patients spend much less time in hospital and
many more undergo an intervention, such as angioplasty, to prevent acute admission.
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 include:

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
ACG MARCH 2015 report. LB
education

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 October 2014 to March 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 is being given to new participants. 30 passes have been
issued since the project started

In total, 33 people have benefitted to date. The variety of paths taken by these
participants is shown appendix 1. This demonstrates the flexibility in what we are
offering, and that a person centred approach can be offered

Development of a new flyer to encourage elective PCI patients to participate in a
programme of cardiac rehabilitation (see appendix 2). Letters go out to these patients
from Ninewells hospital to invite participants to the hospital based rehabilitation. The
cardiac rehabilitation team agreed to include our flyer in order to offer patients the choice
to also exercise in the community. Latest figures are that 9 letters have been sent with 1
person contacting the service. Following assessment he was then referred for a 1-1 gym
programme

Exercise instructor study session in December (see appendix 3). 7 blood pressure
monitors were purchased to give to exercise instructors and a workshop on the use of
these formed the basis of this study session. It was also an opportunity for exercise
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instructors to get together and a chance to acknowledge their contribution to the project

Following on from the study session, the cardiac rehabilitation support nurses (CRSN)
led 8 self-management sessions at community exercise classes. These sessions
educated participants regarding targets for and measuring blood pressure, pulse, BMI
and waist measurement. In total 82 people attended

Blood pressure record cards have been produced (see appendix 4). These are used
by participants in the classes to promote ‘know your numbers’ and facilitate selfmanagement. These have also been distributed to GP surgeries to promote the project

New evening gym class in Forfar for cardiac participants

Supported establishment of a new seated exercise class in the village of Friockheim
led by a BACPR qualified instructor

A further 1 exercise instructor is being supported to gain the prerequisites for BACPR
enrolment later this year, adding to the 2 that the project already supports

Three project personnel attended a 1 day BACPR ‘Monitoring Exercise Intensity’
course. 6 exercise instructors attended a 2 day BACPR ‘Physical Activity & Exercise in
the Management of Cardiovascular Disease Part II: Advanced Application’. Follow up will
take place at a study session planned in May to assess what difference this training has
made to practice, and what further support is required

Education talks have taken place at Forfar branch meetings of ACG on three topicsnutrition, medication, and heart health. Beneficiaries were 18, 22, 18 respectively
What difference we actually made
Participants in the project are asked to complete 3 questionnaires (see ‘How we collected
the information’ below) to assess to what extent we are meeting our stated outcome
measures. Numbers attending self-management sessions with the CRSN were recorded, as
well as any resulting feedback or outcomes. At present, we are able to report on 13
participants who have provided information using the Patient Feedback Questionnaire. The
following is illustrative of the difference we are making:

Of the beneficiaries of the free passes followed up so far, we can report a high
completion rate- 92% have claimed all 8 sessions

‘Very well supported. She [the exercise instructor] noticed the giddiness and toppling
forward when standing up and notified the Nurse who checked my blood pressure and
advised me to see my GP that same day’

‘The classes are well worthwhile. Apart from the extra exercise received, seeing how
others, who have been affected to a much worse degree than oneself, are coping and
ACG MARCH 2015 report. LB
progressing both physically and mentally is most encouraging and gratifying’

‘Phase 3 [hospital based] exercise programme too sedentary for person with 35 year
background of running, cycling and tai chi’
The self-management sessions were well received with feedback such as:
‘Learnt more in 15 minutes from CRSN than in years from all the doctors’
‘Very easy to do myself after being taught how’
In 2 cases an irregular pulse was detected and the participants directed to their GPs for
investigation. A further one person had symptomatic hypotension detected and was also
advised to contact their GP.
Challenges and changes
Recruiting new participants to the programme
This is an ongoing challenge. We had hoped that GP surgeries would identify suitable
patients but despite visits and emails to promote the project in our target areas (Brechin and
Forfar) this has not generated referrals. We assume that this is due to lack of time capacity
within the practices to do this, but this needs explored further. Our next activity to recruit
people is to produce posters which will go out to all GP practices, out-patient departments,
leisure centres, libraries etc. in Angus to appeal directly to potential participants. The draft
poster is attached as appendix 5.
Although we feel current recruitment is low (33 people to date), this does need to be put in
the context of how many people are accessing community cardiac rehabilitation overall.
From October 2013 to March 2015, there were a total of 136 new cardiac participants into
community classes. This includes the 33 directly associated with the project. Therefore,
24% of new participants are benefitting from the new opportunities offered by the project.
Because of the problems with recruitment as described above, the new evening gym class
in Forfar has needed extra support. We want to ensure that the class is kept running long
enough to allow time for new people to be recruited. We have therefore allowed existing
cardiac participants, as well as some non-cardiac participants to attend for the 8 sessions.
Because attendees haven’t been ‘new’ cardiac participants, the CRSN no longer attends but
when this changes, she will be available to offer support.
Learning for the future
Evaluation
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There are a number of things we will do differently in our evaluation due to experiences so
far:

Currently the CRSN is following up at 8 weeks. However it would be better to do this
after 12 weeks to allow for holidays/illness as we are finding that many people do not
complete all sessions within 8 weeks. It will also be useful to follow up after this to see
how many people continue to participate in physical activity after their 8 free sessions.
We will look into how this can be achieved

Data quality is reduced when postal questionnaires are given- reduced feedback and not
always returned. Although more time consuming, face-to-face feedback should be
sought where possible

Our quantitative evaluation needs reviewed. Return rates on pre- and postquestionnaires have been low. The Wellbeing Evaluation Questionnaire seems to have
been poorly understood by some participants, and may not be an appropriate tool in its
current form or may need to be given out with some verbal explanation
How we collected the information
New participants are assessed either by our CRSN or by NHS Cardiac Rehabilitation Staff
according to established protocols. We have 3 questionnaires to assess the difference we
are making (all included in the September 2014 report):

Outcome Evaluation Questionnaire. We ask participants to complete this before they
start the programme (if no prior cardiac rehabilitation input), and after 8 weeks

Wellbeing Evaluation Questionnaire. This is completed before they start the
programme (with or without previous cardiac rehabilitation input), and after 8 weeks

Patient Feedback Questionnaire. We ask participants to complete this in conjunction
with the CRSN at the 8 week follow up meeting
How we spent the money
Details of the expenditure are included below (appendix 6). The actual spend to date (for 18
months of funding), actual 6 month spend, and the projected 6 month spend (to include
March 2015 spend) is shown.
We have spent 80% of our total funding to date. We expect that for the period October 2014
to March 2015 we will have achieved 97% spend from that £21,695 payment. We therefore
have only a small underspend from this 6 month reporting period. However, due to factors
explained in this and in previous reports (lower numbers recruited to project than anticipated
and consequent delay in requiring a second CRSN), we do have an ongoing underspend.
ACG MARCH 2015 report. LB
This is estimated at £9,825.
Areas that show significant variances from the budget are:
Time: Our overall time costs still show an underspend due to the delay in our second CRSN
starting, and there being fewer new participants to support. We will also have to make
adjustments for the final 6 months because our original CRSN is due to leave the project in
mid-April.
Training: Supporting the new CRSN to undertake the course ‘Current Perspectives in
Cardiac Care’ is resulting in higher costs than anticipated due to the study time involved.
However this training will be of considerable benefit to the project and we anticipate that it
will also benefit community cardiac rehabilitation provision in the long term.
Timely access to training has always been an issue for us (suitable training courses take
place in Scotland more infrequently than we would like). Therefore we have been taking
advantage of online courses, and have put another BACPR instructor on the level 3
Exercise Referral course. This will broaden that instructor’s knowledge of additional clinical
conditions that cardiac participants may have.
Research has shown that people with severe mental health problems are two to three times
more likely to suffer from cardiovascular disease due to medication and lifestyle factors
(https://www.bhf.org.uk/heart-health/preventing-heart-disease/heart-and-mental-health). We
decided that some of our underspend should be reallocated to pay for one of the BACPR
instructors (who is also the Project Coordinator) to go on the Level 4 course Exercise and
Mental Health. This was seen as a good opportunity to assess the usefulness of this training
for our programme in the future, but also key learning can be shared at future exercise
instructor study sessions.
We will also consider funding further training for our BACPR instructors (e.g. ACPICR
‘Principles and Applications of Resistance Training for Health Care Professionals in Cardiac
Rehabilitation’) as an appropriate use of any underspend.
Pilot Courses: It is likely that we have overestimated the numbers that will take up the 8
free sessions. However we will retain the allocation for this in the budget as we still hope to
recruit more people with ongoing promotion and advertising. But we will review this
monthly.
Appendices
Appendix 1: Pathways of beneficiaries accessing community physical activity
Appendix 2: Flyer to promote project to Ninewells elective PCI patients
Appendix 3: Programme for Exercise Instructor Study Session, December 2014
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Appendix 4: Blood Pressure Record Card
Appendix 5: Poster advertising programme
Appendix 6: Budget & expenditure summary
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Appendix 1: Pathways of beneficiaries accessing community physical activity
Exercise type
Route of entry
Self-referral
Immediate entry (no
phase 3)
Early entry (before
completing phase 3)
Concurrent with
phase 3
After completing
phase 3
Concurrent
recruitment to Heart
Failure Project
Private
gym
Circuit
Class
1-1 gym
programme
Seated
exercise
Gym
class
2
4
4
3
2
1
1
2
3
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7
4
Appendix 6: Budget and expenditure summary
BUDGET
Alliance Funding
Time
Travel
Training & Development :
Training
Travel & Accommodation
Equipment
Pilot Courses
Promotion
Monitoring & Evaluation
Administration & Documentation
ACTUAL
18 Month
SPEND
TO 10/03/15
6 MONTHS
PROJECTED
SPEND
TO 31/03/15
£65,085
£65,085
£21,695
£21,695
37386
6035
27564
5124
9518
2128
12032
2583
3360
4204
7402
1450
2574
45
3169
145
6125
2160
3475
600
1740
5265
523
2816
0
1631
472
322
1684
0
796
1632
473
572
0
418
65085
51775
80% Spend
17539
81% Spend
21024
97% Spend
£0
£13,310
£4,156
£671
Underspend
March 15 Projection Spend
£3,485
Projected 18mth Underspend @ 31 March 2015
£9,825
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6 MONTHS
ACTUAL
SPEND
TO 10/03/15