I was delighted to read Dr Weilers editorial which eloquently presents many of the issues currently faced in exercise medicine. It is so important to debate this subject-particularly as we are in a unique position in the U.K to effect permanent change.
I was interested in Dr Weilers’ view that the introduction of the GGPAQ into QOF would be a valuable place to start what will have to be a process of cultural change. I would like to debate this opinion further. It has been clearly established in the literature that changes in physical activity levels in the long term are not easy to effect. The most successful interventions involve patient centred, long term, well supported, behaviourally based interventions delivered by highly motivated and well trained medical professionals. I do not agree with your statement that ‘brief interventions (3-10min) can lead to substantial increases in physical activity level (by around 30%)’. I am not aware of any evidence to substantiate this claim, particularly in the long term. The studies which have shown these sorts of results have used of a much more intense intervention, not sustainable within the NHS, and most do not show significant long term results (greater than 3 months).(1,2)
I agree that physical activity promotion to ‘healthy’ populations can only be delivered by primary care. I feel, however, that we are not yet ready for GGPAQ. The effect of creating another ‘box to tick’ in an already target driven culture, I feel, at this stage would be counterproductive. We have a long way to go in the process of educating G.P’s and practice nurses about the evidence base for the benefits of and the delivery of exercise prescription. It will, rightly, take convincing evidence of effectiveness to persuade G.P’s to engage in this process. There is, currently, no evidence that could possibly lead us to suppose that the introduction of GGPAQ would lead to significant and sustained changes in physical activity levels ?1million , to introduce a QOF point does not seem an enormous amount of money until you consider that with that sum, per year, you could employ 10 SEM consultants. I feel this would be a very much more effective way of spending the limited resources available at this stage. A single SEM consultant could provide a comprehensive education programme from medical school to primary and secondary care, could lead good quality, translational research into cost effective ways of delivering exercise interventions and could coordinate existing services for exercise in chronic disease which are often non-existent or ineffective and poorly evaluated. They could assess local needs, building on strengths of existing structures and working on the weaknesses. They could improve links with the fitness industry which in many cases are poorly supported and therefore less effective.
I agree, clinical research is essential at this stage and funding is not easy to come by. The N.H.S needs to address this through its own research organisations. Partnerships with the tremendously powerful fitness industry may also help to fund translational research as might charitable foundations for chronic disease research. Overall, I agree with much of the editorial, but feel that in the current economic climate , we need to think very carefully before rolling out blanket schemes which are open to criticism from the very people we are hoping will deliver them.
Natasha S. Jones
ST6 in SEM
1.Eakin EG, Glasgow RE, Riley KM. Review of primary care-based
physical activity intervention studies: effectiveness and implications for
practice and future research. J Fam Pract. 2000; 49: 158-168.
2. Lawlor D.A The Effect of physical activity advice given in primary care
consultations-a review. Journal of public Health Medicine.2001; 23:219-226