By James R Griffiths
In 2006 NICE concluded that there was insufficient evidence to recommend the use of exercise referral schemes (ERS) to promote physical activity, other than as part of research studies where their effectiveness can be evaluated. Despite this, there are approximately 600 ERS in the UK that primary care have access to. We looked at referring patients into the ERS in Barnsley (run by Barnsley Premier Leisure) from the Emergency Department.
Patients who attended the Emergency Department over a six-month period were screened for the exercise referral scheme. Posters were placed in the department advertising the scheme and encouraging patients to get more detail from a member of staff. Patients who met the inclusion criteria had a referral form faxed to their GP or practice nurse asking them to refer the patient on to the scheme.
Over the six-month period, 26 patients were referred to their GP or practice nurse. Of these only 10 were subsequently referred on to Barnsley Premier Leisure and only 3 patients attended for an initial assessment. No patients completed the 24 gym or swim sessions.
The results of this pilot study are obviously disappointing. We have tried to identify the barriers preventing patients from completing the scheme and have made changes to the way patients are referred onto the scheme.
We are hopeful that with better engagement from patients and GPs, we will be able to recruit patients on to the exercise referral scheme from the ED.
Regular physical activity can reduce the risk of developing many chronic conditions and improve the conditions of chronically ill patients suffering from coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal conditions. Recent Department of Health guidance recommends 150 minutes of moderate intensity physical activity per week for adults aged 19-64. It is estimated that only 39% of men and 29% of women are meeting this target.
In 2006, the National Institute for Health and Clinical Excellence concluded that, there was insufficient evidence to recommend the use of exercise referral schemes (ERS) to promote physical activity, other than as part of research studies where their effectiveness can be evaluated. Despite this, there are approximately 600 ERS currently in the UK that primary care practitioners can access.
Barnsley Premier Leisure (BPL) instituted an ERS in 2009 whereby suitable patients were referred onto the scheme by their general practitioner. Patients would receive an initial assessment followed by 24 free gym, swim or fitness class sessions delivered by appropriately trained personnel. Following a meeting between the author and BPL it was decided to screen patients in the Emergency Department (ED) at Barnsley Hospital NHS Foundation Trust to see if they could be referred onto the scheme.
After staff awareness sessions and placing posters and leaflets in the department, a 6-month pilot was undertaken to evaluate whether patients were being referred (if appropriate) and whether these patients actually entered onto the scheme.
Patients who met the inclusion criteria were offered referral onto the scheme by ED staff and a letter was then faxed to the patient’s GP or practice nurse asking them to refer the patient onto the scheme. For funding reasons, it was not possible to directly refer patients onto the scheme from the ED.
A record was kept within the ED of all patients referred onto the scheme and, each month; this list was forwarded to BPL to cross-reference with patients that had been referred by their GP.
Over the six-month period, a total of 26 patients were referred to their GP or practice nurse. Of these only 10 were subsequently referred on to ERS by their practice and only 3 patients attended for an initial assessment.
To date no patients out of the 3 referred have completed the 24 sessions.
In the past 12 months ERS has had an uptake of 995 patients via general GP referrals. Of which 31% of the patients have completed & improved their health conditions. They continue managing their health through increased physical activity which arguably reduces the overall cost the NHS.
The results of this pilot study are obviously disappointing. Despite regular meetings between ED staff and BPL to understand the barriers to referral, the uptake to the scheme has been poor. Several reasons have been put forward for this:
- ED staff, despite training, were unfamiliar with the scheme and unsure how to approach patients who may benefit from regular physical activity. It was hoped that by placing posters and leaflets in the ED, that patients would approach staff, making the initial conversation much easier.
- Time pressure and other concerns within the ED such as the 4-hour access standard, meant that practitioners may not have had adequate time to explain the scheme to patients.
- Patients may have been quite motivated to start the scheme whilst they were in the ED, but the inherent delay between the ED referral to GP and the actual ERS starting may have meant that the patient was less inclined to start the scheme.
- A lack of awareness amongst GPs and practice nurses that ED staff would be referring patients onto the ERS via primary care. We tried to raise awareness by communicating with GPs in Barnsley and including the ED in the ERS newsletter.
Regular meetings took place between the ED and BPL while the pilot scheme was running to try and address barriers to referral. The way patients were referred onto the scheme was changed to put the onus on the patient rather than the GP (as less than half of those referred from ED were actually referred onto the scheme by primary care) but
Recognised barriers to patients not adhering to ERS include low motivation and lack of time. This was a Swedish-based study with a non-adherence rate of only 28% (much lower than the BPL scheme). Although this paper is not entirely applicable to a UK population, it is interesting to see the two highest causes of non-adherence. This is an area that could be looked at further with the ERS in Barnsley.
A systematic review in 2011 found levels of uptake between 35% and 100% and levels of adherence of 12-82% across studies. A more recent systematic review showed a pooled level of uptake of 66% (95% CI 57-75%) across observational studies and 81% (95% CI 68-94%) in RCTs. The pooled level of ERS adherence was 49% (95% CI 40-59%) across the observational studies and43% (95 CI 32-54%) across the RCTs. This also showed large heterogeneity between the studies that looked at the effectiveness of ERS. The authors concluded that referral by letter appeared to produce lower uptake rates than face-to-face consultation with a healthcare professional which may have implications for how our referral scheme could be improved.
It is clear that the levels of uptake and adherence in this pilot study fall well short of what is achievable in primary care and, in fact, performance for this cohort was much lower than the other patients referred onto the BPL scheme (overall adherence 31%). From this evidence, it is unlikely that referring patients from the ED onto exercise referral schemes will be successful.
Unfortunately, funding has been withdrawn for the ERS in Barnsley as of April 2013 and the scheme is set to close unless further financial support can be found.
- World Health Organisation. Global recommendations on physical activity for health. Geneva: World Health Organisation,2010.
- Department of Health. Start Active, Stay Active. London: Department of Health,2011.
- The Health and Social Care Information Centre. Health Survey for England 2008. Leeds: The Health and Social Care Information Centre,2009.
- National Institute for Health and Clinical Excellence. Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community based exercise programmes for walking and cycling. London: National Institute for Health and Clinical Excellence 2006.
- Leijon ME, Faskunger J, Bendtsen P et al. Who is not adhering to physical activity referrals, and why? Scand J Prim Health Care 2011;29:234-240
- Pavey TG, Anokye N, Taylor AH, et al. The clinical and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2011;15(44)
- Pavey T, Taylor A, Hillsdon M, et al. Levels and predictors of exercise referral scheme uptake and adherence: a systematic review. J Epidemiol Community Health 2012;66:737-744
James Griffiths, Consultant in Emergency Medicine, Barnsley Hospital NHS Foundation Trust