West Cumbria Primary Care Trust covers a population of 138,000 in an area of 13000 km2. National statistics show that coronary heart disease accounts for 24% of deaths in males and 10% of deaths in females under the age of 65 years.1 West Cumbria figures are considerably higher at 32% and 25% respectively.2 One of the aims of the North Cumbria Health Improvement Programme (HIMP) 2001-2004 is to reduce the incidence of CHD and the number of premature deaths.3
West Cumbria Council for Voluntary Service (CVS) aimed to develop a community CHD health initiative that would address these problems, targeting those on low incomes, without private transport, the rurally isolated and the elderly.
The GP practice made office space available in the cottage hospital in Maryport for a health development worker, to work alongside the community healthcare team. An initial consultation period during which the views of GPs, their staff and patients were sought, showed that there was not enough support for patients recovering from a coronary event.
As a result, it was decided to create a pilot project to deliver a phase 4 cardiac rehabilitation service (see Box 1below). The opportunity arose when West Cumbria CVS took on the lease of the former GP surgery with the intention of creating a health resource centre for Maryport.
Box 1: The four phases of cardiac rehabilitation
Setting up the Heart Workshop
The project began with the recruitment of a team of four volunteers, all of whom were qualified fitness instructors. The West Cumberland Hospital rehabilitation team developed a 5-week training programme for the volunteers, who already held First Aid certificates. The training covered:
- An introduction to cardiac rehabilitation
- Basic anatomy and physiology of the heart
- The pathophysiology of coronary heart disease
- Benefits of exercise in CHD patients
- Cardiopulmonary resuscitation
- Medication in coronary heart disease.
The volunteers, known as cardiac rehabilitators, were later trained in the use of a defibrillator and in delivery of the Heart Manual, a cognitive behavioural rehabilitation tool for patients during the immediate post-MI period (see •New SIGN guideline underlines importance of cardiac rehabilitationê). The Maryport team also visited West Cumberland Hospitalês new phase 3 rehabilitation unit to talk to staff and patients there.
The Heart Workshop programme began on 6 March 2001 with the aim of addressing the health needs of individual CHD patients in a holistic way. Phase 4 cardiac rehabilitation sessions and Healthy Heart Workshop sessions are held two days a week, four sessions per day.
Patients who have undergone a coronary artery bypass graft or a myocardial infarction are referred to the project for cardiac rehabilitation, if suitable, from the West Cumberland Hospital.
Local GPs and practice nurses can refer patients with risk factors for CHD to the Healthy Heart Workshop sessions. Patients also self-refer to this scheme, which offers the same facilities as the cardiac rehabilitation programme.
Exercise training is a core element of the cardiac rehabilitation programme, and each patient follows a 12-week, mostly gym-based exercise course.
The training is geared to the individual, and takes into account his or her level of fitness rather than imposing a set programme that might be difficult to follow and result in a sense of failure.
Along with the exercise programme, we provide a strong support network. The patients play a large part in deciding what changes to make to their own lifestyles;4 they feel empowered and are therefore more likely to maintain these changes.
The cardiac rehabilitators relate well to patients and their families; patients feel free to voice their worries and fears, and the team helps them to find their own resources to deal with their concerns.
Patientsê partners, many of whom also have poor health, are welcome to use the programme. Patients and partners together choose which activities to integrate into their lifestyles when they finish the gym-based exercise sessions.
This ongoing mutual support increases the likelihood that change in behaviour will be maintained.
Maintaining lifestyle changes
Most patients admit that they are unlikely to continue with gym-based exercise after the 12-week programme ends. Towards the end of the programme therefore we introduce a variety of other physical activities that patients can more easily integrate into their lifestyles.
These activities include walking, golf, tennis, swimming and exercise sessions run by local •health activistsê. Our new guided walks project has attracted more than 40 people, and 18 people have asked to train as volunteer walk leaders.
These spin-off activities are now largely self-supporting as they have become the focus of patientsê and familiesê social lives. Heart Workshop users can also:
- obtain advice on benefits and housing;
- receive support to stop smoking - there is fast, direct referral to the smoking cessation clinic whereas previously there was a 6-8 week wait;
- join a food co-op. Initially one food co-operative was set up; families who register pay £2 per week for fruit or vegetables that are obtained wholesale. More than 200 families are now registered with three food co-ops in Maryport;
- obtain loans at very low interest rates from the credit union.
Approximately 400 people have used the health resource centreês services. The Heart Workshop has worked with 17 patients recovering from myocardial infarction, 13 patients who had a coronary artery bypass graft, and 16 of their partners. To date, no patient who has used the Heart Workshop has had a recurrence of myocardial infarction. The project is in line with the NHS Plan to provide local services focusing on patient needs.
The Heart Workshop project is being audited using the SF-36 Health Survey.5 We are also using a questionnaire to ask patients what impact the project has had on their lives. We plan to follow up each patientês progress at 1 year and 2 years after they leave the project.
One measure of success is the fact that patients continue to use the project and to involve their partners or family members.
In July 2001 the Heart Workshop won the National Health and Social Care Awards 2001 for Improving the Lives of People with Heart Disease.
In November that year the project won the Northern and Yorkshire Excellence Award 2001, Coronary Heart Disease Award.
Before the hospital and the Heart Workshop projects were set up, there were no phase 3 or 4 cardiac rehabilitation services in West Cumbria.
This project involves different sections of the community working together for the first time to create a coherent cardiac rehabilitation service that is local, accessible and delivered in a friendly, non-medical environment.
A multiagency group of health professionals has recently produced a community phase 4 cardiac rehabilitation strategy for West Cumbria. The group has identified the Heart Workshop as the model to replicate and has recommended a programme to roll out phase 4 cardiac rehabilitation across areas of need in West Cumbria.
The North Cumbria Health Action Zone has recently released funding for a community cardiac rehabilitation manager for 12 months, to implement the strategy.6
Both patients and the volunteer Cardiac Rehabilitators are involved in making decisions about the way the Heart Workshop project develops. This has given users a sense of ownership. We now have a waiting list for patients and their families to join the Heart Workshop.
The health development workerês 3-year post was jointly funded through the Governmentês Single Regeneration Budget, the Francis C. Scott Trust and Lloyds TSB trust funds.
- Department of Health. Saving Lives: Our Healthier Nation. London: TSO, 1999.
- North Cumbria Health Action Zone. Strategy for Community Based Cardiac Rehabilitation (Phase IV) in West Cumbria, 2002.
- North Cumbria Health Authority. North Cumbria Health Improvement Programme 2001-2004. North Cumbria Health Authority, 2002.
- Gabbay J. Our healthier nation: Can be achieved if the demands allow it. Br Med J 1998; 316: 487-8.
- Ware JJ, Sherbourne CD. The MOS 36-item short-form health survery (SF-36). I. Conceptual framework and item selection. Medical Care 1992; 30: 473-83.
- North Cumbria Health Authority, Cardiac Disease Advisory Group. Bid to Address Inequalities in Cardiac Rehabilitation across North Cumbria. HAZ bid. North Cumbria Health Authority, August 1998.
For further information on the Heart Workshop progremme, contact Janette Baines at: Maryport Resource centre, 12a Selby Terrace, Maryport, Cumbria CA15 6NF Tel: 01900 819191; fax:01900 818757 Email: firstname.lastname@example.org