Professor of Health Service Research, Adrian Taylor, discusses motivation, exercise schemes, and the future impact on the NHS
Physical inactivity, which results in conditions such as obesity, type 2 diabetes, low mood, and high blood pressure, costs the NHS over £455 million every year – and the contribution to excess morbidity and mortality since the COVID pandemic have still to be calculated.
Exercise not only helps people with long-term conditions better manage their health but also boosts the immune system. So how can we support more people to be physically active?
It’s not just about putting on different sessions and telling people to exercise. Joe Wicks gained national praise for his online exercise sessions during lockdown, but those who took part chose to do so – and many other people didn’t. It’s also clear from the NHS figures and existing research that the threat of a worsening health problem isn’t a big enough motivation on its own to encourage everyone to exercise. There has to be something more.
People with multi morbidities are often prescribed medication as the first line of treatment, because supporting lifestyle changes may be seen as more challenging within primary care.
For over 20 years, GPs have been referring patients with long-term conditions such as type 2 diabetes to an Exercise Referral Scheme (ERS), involving aerobics and strengthening along with less strenuous mindful activities like yoga. In addition, or instead, individuals could be referred to community support to find ways to become more physically active, depending on their needs.
Despite the obvious benefits for some people who are referred and engage in schemes, figures show that overall new ways are needed to improve patient uptake and adherence, since approximately three out of every 10 patients referred don’t ever turn up to meet the exercise professional, and less than half then complete the programme.
I recently led a UK-wide team to create a web-based support package (e-coachER) to complement the usual referral scheme in Plymouth (EveryOne Active), Birmingham (BeActive) and Glasgow (LiveActive) and to assess if it was more effective in supporting an increasing device-assessed physical activity over 12 months, than the exercise referral scheme alone. The team consisted of researchers, stakeholders involved in commissioning and delivering referral schemes, and patients with experience of schemes.
Half of the recruited 450 inactive participants with chronic physical and mental health conditions received the additional e-coachER support package, and half didn’t.
The study, which was funded by National Institute for Health Research (NIHR) Health Technology Assessment and published in the British Journal of Sports Medicine, showed that of the 224 participants offered the e-coachER support, approximately two-thirds engaged with the online system. The web-based support only had a small effect on participants’ moderate to vigorous physical activity and we can’t be confident this was not due to chance.
This is disappointing, but the findings reiterated just how challenging it is to support changes in physical activity among people with existing chronic conditions who are particularly inactive.
Providing a basic pedometer to record daily steps, and access to a website explicitly designed to encourage self-monitoring and goal setting, and overcoming barriers to attending the referral scheme and broader physical activity, wasn’t sufficient to augment the usual exercise referral scheme in terms of total minutes of moderate and vigorous physical activity recorded with accurate monitors worn by participants 12 months later.
The five-year study was supported by the NIHR Applied Research Collaboration for the South West Peninsula (PenARC) and the Peninsula Clinical Trials Unit within the University of Plymouth. In Plymouth, the City Council subsidised attendance at the Life Centre and Brickfield for people from GPs surgeries in more economically challenged areas of the city to ensure the study didn’t contribute to health inequalities by only involving those who could afford to attend the gym.
At a time when we need to be taking all the pressure we can off the NHS, we need to know more about how best to support people to be more physically active in a sustainable way. The global epidemic called obesity, high prevalence of poor mental health and increasing health inequalities have been highlighted even more so during the COVID pandemic. Further ways are needed to support people in making important changes to manage their health – and finding other ways than those used in the present study needs to be a research priority.
The full study Randomised controlled trial of an augmented exercise referral scheme using web-based behavioural support for inactive adults with chronic health conditions: the e-coachER trial is available to view now in the British Journal of Sports Medicine (doi: 10.1136/bjsports-2020-103121).
The corresponding report for the NIHR, entitled Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER Randomised Controlled Trial, is available to view on the NIHR website.