How do exercise referral schemes work?

Exercise Referral was announced by the NHS in 2001. Although it is now over a decade old many people are still not aware that it exists. The scheme was launched so that obese patients can be referred to specialist fitness instructors and nutritionists who will then in turn provide advice and guidance. Doctors do not have the time or resources to help individuals adjust their diet and activity levels to lose weight, but personal trainers and other fitness professionals do. The scheme is a way to allow fitness professionals to work in partnership with healthcare professionals.

The main aims of an exercise referral scheme are to:

• Reduce coronary heart disease
• Reduce diabetes and other obesity related illness
• To teach people how to exercise to improve fitness
• Encourage people to make permanent lifestyle changes and make exercise a part of a weekly routine
• To improve mental health as well as physical health
• Reduce risk of falls in older patients

Who Can Be Referred?

Exercise referral is not just for those who are obese. It covers a range of medical conditions including:

• Rheumatoid arthritis
• Depression
• Diabetes (Type 1 and 2)
• Hypertension
• Anxiety / Stress
• Osteoporosis
• Osteoarthritis
• Asthma
• Obesity (BMI over 30)

If you have any of the above conditions and feel that you require some guidance and motivation with exercise you may be eligible.

What Information Is Used In The Referral?

Your doctor will take some health data and use this to help a fitness instructor develop a tailor made regime for you. Typically the following will be tested during your consultation:

• Your resting heart rate
• Is your heart rate regular?
• BP Systolic
• BP Diastolic
• Hypertension?
• Ischaemic Heart Disease?
• Asthma?
• Diabetes?

The referring doctor will prescribe a level of intensity for the exercise ranging from low to low.

A doctor may also request that a patient avoids specific activities, such as:

• Cardiovascular fitness
• Mobility Class
• Weigh Training
• Aquafit
• Yoga
• Swimming

These will be dependent on each individual patient as some conditions can make some of these activities unsafe.

Example of a Referral Form

This is a copy of Bristol Primary Care Trust’s Active Choices Referral Form (ACRF2).

 

It gathers a lot of information on each patient to ensure that they receive the best fitness advice possible that is tailored to their needs and skills.

Patient Activity Forms

The scheme requires that patients complete activity forms to log / track all the exercise that they are performing. The main purpose of this form is to check that a patient is following the exercise scheme, but the log will provide valuable information which is needed when adjusting the exercise regime.

The activity forms record a patients height, weight and BMI, as well as heart rate before and after exercise, and blood pressure. The form will also record the start date and a review date.

The exercise log keeps a record of the type of exercise performed, how many times a week it is performed and the intensity levels.

Typical Activities

A fitness instructor will typically recommend cardiovascular exercise, strength training and walking, or a combination of all 3. Many local authorities organise health walks now, which are group walks through local parks and green spaces. Some gyms also provide Aquafit sessions, which are swimming pool based exercise classes.

Requirements of an Exercise Professional

For a fitness instructor / personal trainer / strength coach to be considered for the exercise referral scheme they must:

• Be on the Exercise Register
• Have Professional Indemnity Insurance
• Meet National Occupational Standards for Exercise Programming
• Have appropriate resuscitation skills
• Adhere to Client Confidentiality

You can search the register of exercise professionals for instructors in your area.

What A Fitness Professional Must Do

There are several tasks that a fitness professional must carry out when a patient has been referred to them:

• Carry out a pre-exercise assessment
• Obtain patient consent
• Motivate the patient
• Cater for specific health outcomes
• Supervise the patient during exercise
• Monitor and log progress
• Discuss long-term physical fitness
• Report outcomes to the referring GP

It is then up to the doctor to provide a patient review and carry out health assessments, and also to encourage lifetime maintenance of the exercise programme.

How To Be Referred

The first step now is to make an appointment with your doctor to discuss your options. A quick assessment will determine if you are eligible to be placed on the scheme. If you are registered with a GP you can search the NHS for GP’s in your area here: http://www.nhs.uk/service-search

Each county / NHS clinical commissioning group may manage its exercise referral scheme in a slightly different way. Each area of the country has its own scheme, for example:

• Mid Essex CCG – Live Life GP referral scheme
• Preston – Physical Activity Programme
• Burnley – Healthy Lifestyles
• Suffolk – Active 4 Life

Many are simply called an Exercise on Referral Scheme. The first step is to make an appointment for yourself or somebody in your care and request an assessment to see if you are eligible for referral.

Has Exercise Referral Improve Overall Health?

The scheme is over a decade old now. Do we have proof that it works?

In 2011 a research paper was published which looked at the effectiveness of exercise referral schemes on physical activity levels and health outcomes – i.e. are people more active and healthier as a result of the initiative?

While the study did find that some people were more active as result of the scheme, and that some individual studies had found that patients on exercise referral had lower average BMI, the overall conclusion was:

“Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.” (Pavey, 2011)

Overall the evidence for exercise referral as an effective way to increase fitness levels and reduce obesity related illness is weak at best. However, there is definitely some advantages to such schemes and it is hoped that in time the results of the first schemes can be used to develop new methods and initiatives with higher success rates.

A study into the impact of exercise referral in Wales providing some more positive results:

“For participants referred with CHD risk factors only, there was a significantly increased likelihood of increases in physical activity and a statistically significant decrease in level of anxiety and depression for those in the scheme”. Murphy, 2010.

The Welsh study also highlighted most people only increase exercise in the short-term – presumably during the initial 12 week exercise program – but certain populations do maintain exercise in the longer term. The key is for people to become more internally motivated, i.e. self-motivated, to exercise on a regular basis.

Self Motivation Is Key To Success

One of the key aspects of such a scheme has to be a focus on motivation.  Often overlooked, motivation is what drives people to exercise and make positive changes. While education and resources are important, without the desire to take action change is impossible.  A fitness instructor can only motivate an individual in the gym / classroom, it is ultimately up to the patient to find ways to stay motivated.

References

The full research paper is available via Open Access for all to read:

“Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis” by T G Pavey (and others), BMJ 2011;343:d6462 doi: 10.1136/bmj.d6462

Welsh government publication:

“The evaluation of the National Exercise Referral Scheme in Wales” Simon Murphy (and others) Ymchwil gymdeithasol Social research. Number: 07/2010

“A pragmatic randomised controlled trial of the Welsh National Exercise Referral Scheme: protocol for trial and integrated economic and process evaluation” Simon Murphy (and others). BMC Public Health Volume 10

Referral form from: http://www.bristol.gov.uk/page/health-and-adult-care/bristols-exercise-referral-scheme

Further Advice

“Specialist referrals and services your GP may recommend” NHS. Accessed 09/09/13.