Exercise Referral Schemes in Primary Care: Where does Sport and Exercise Medicine stand?

By Dr. Amir Pakravan and Dr. Amanda Jones

Exercise referral schemes (ERS) are often known as specific referrals made by primary care professionals to a third party for individual advice, and a tailored physical activity or exercise programme aimed at achieving health benefits through increased level of physical activity.[1, 2]

Primary care is uniquely placed to promote physical activity at a number of levels and ERS is one of many different ways by which Primary Care professionals can promote physical activity.[2-5] This is usually offered to selected individuals who are deemed to achieve specific health benefits from such tailored programmes.

swimmin in waterConsidering huge direct and indirect healthcare cost of physical inactivity which with conservative estimates is in excess of £900 million per year for England,[6] physical activity is now one of Public Health Outcome indicators. However, many of the other outcome measures of this framework such as people’s weight, over 65s falls sufferers, smoking levels, diabetes, self-reported wellbeing, and death from heart disease and stroke are also directly or indirectly influenced by population’s levels of physical activity.[7]

There is an obvious paucity of sufficient scientifically robust evidence for effectiveness of exercise referral schemes in absolute health risk reduction and economic efficiency, and despite some evidence for improvement of levels of physical activity in ERS participants, there are major questions about significance and sustainability of this increase and whether this would be an efficient use of resources particularly when counselling, advice, and walking have also been shown to provide similar benefits.[1, 2, 8-11]

Previous guidelines by the National Institute for Health and Care Excellence (NICE) restricted endorsement of any ERS by healthcare professionals only to those schemes evaluating a number of measures as part of a designed and controlled research project.[4] Nonetheless, with more than 600 currently active ERSs in the UK, these guidelines have clearly not affected increasing popularity of these schemes. This may in part be due to a lack of controlled trials, but may also reflect a fundamental difference between available evidence and the real feel and health or social benefits experienced on the ground which may have not been sufficiently documented by providers and participants of the schemes.

NICE guidelines on ERS are currently under review and due to involvement with an ongoing project looking into ERSs in Suffolk, one of the authors had the opportunity to sit in one of the NICE Public Health Advisory Committee (PHAC) meetings as a public attendee.

Discussions in the meeting further confirmed the notion that despite significant uncertainties in health and economic effectiveness of ERS, the guidelines needed to change to reflect and help refine current practices whilst encouraging further research. It was acknowledged that one of the main obstacles in strengthening evidence base for effectiveness of ERS is a clear lack of appropriate data sets.

The significant variability of schemes on offer makes it even more difficult to agree on a precise definition for ERS; however it appears the scope of future NICE guidelines may well be restricted to general physically inactive individuals without a specific medical diagnosis. This is in contrast to the majority of current schemes where, as opposed to healthy lifestyle service providers, only specific health and medical conditions are included on the exercise referral programme. The key question appears to be whether an ERS is primarily a specific and targeted health intervention with specific outcome measures, hence the term, “Referral”, or only another way of promoting physical activity in general which in turn is expected to lead to general health benefits.

What was noticeable though, was an absence of a representation from Sport and Exercise Medicine (SEM) on the discussion panel and a lack of acknowledgement of potentially significant role this specialty can play in all aspects of the design, implementation, delivery, and ongoing assessment of the service.  Involvement of SEM specialists with the right skill sets and experience alongside Public Health, Primary Care, Research scientists and service providers can potentially result in a more efficient model where selection and injury or medical risks are minimised, appropriate data sets are collected to a high standard, participant motivation is maintained, and further effective health and behavioural interventions and follow up are made possible.

This is obviously open to debate and it is only through active involvement of the SEM community with the process that possible alternative models can be identified.

In view of the Fresh Approach in Practice document published by the Faculty of Sport and Exercise Medicine,[12] it is prudent that the specialty establishes its role in the wider provision of health and exercise services to general population through active participation in guidelines and policy making processes, and further involvement with implementation of such policies.

NICE draft guidelines on ERS will be published on March 19th for a 6-week period of public consultation,[13] and SEM practitioners are encouraged to take part in the process as stakeholders and to raise awareness about the numerous ways in which this specialty can contribute to addressing the current myriad of challenges and shortcomings (go to NICE website for more information).

REFERENCES:

1)     Pavey TG, Taylor AH, Fox KR, et al. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ. 2011 Nov 4;343.

2)     Isaacs AJ, Critchley JA, Tai SS, et al. Exercise Evaluation Randomised Trial (EXERT): a randomised trial comparing GP referral for leisure centre-based exercise, community-based walking and advice only. Health Technol Assess. 2007 Mar;11(10):1-165.

3)     National Institute for Health and Care Excellence website. Accessed Feb 2014. Physical activity overview.  https://pathways.nice.org.uk/pathways/physical-activity

4)     National Institute for Health and Care Excellence. NICE public health guidance 2: Four commonly used methods to increase Physical Activity. Mar 2006.

5)     Department of Health. Exercise Referral Systems: A National Quality Assurance Framework. London 2001.

6)     Sport England website accessed Feb 2014. PCT table (cost of physical inactivity). http://www.sportengland.org/media/86934/PCT-table-FINAL.pdf

7)     Public Health England. Public Health Outcomes Framework: quarterly data update. Feb 2014.

8)     Pavey TG, Anokye N, Taylor AH, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess. 2011 Dec;15(44):i-xii.

9)     Orrow G, Kinmonth AL, Sanderson S, et al. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ. 2012 Mar 26;344.

10)  Williams NH, Hendry M, France B, et al. Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review. Brit Jour Gen Prac. 2007 Dec: 979-86.

11)  Hanson CL, Allin LJ, Ellis JG, et al. An evaluation of the efficacy of the exercise on referral scheme in Northumberland, UK: association with physical activity and predictors of engagement. A naturalistic observation study. BMJ Open 2013;3:e002849.

12)  The Faculty of Sport and Exercise Medicine UK. Sport & Exercise Medicine: A Fresh Approach in Practice. A National Health Service Information Document.

13)  National Institute for Health and Care Excellence website accessed Feb 2014. http://guidance.nice.org.uk/PHG/76

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Dr Amir Pakravan is a Sport and Exercise Medicine Registrar with experience within elite sports and pre-hospital care, and is currently running a project under Public Health Suffolk looking into Exercise Referral Schemes.

Dr Amanda Jones is Assistant Director of Public Health, and Lead Consultant for Health Protection and Health Improvement in Suffolk.

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