YESTERDAY, TODAY & TOMORROW? EXERCISE REFERRAL YESTERDAY, TODAY & TOMORROW? A summary of the history, development, practice and evidence . By Malcolm Ward & Huw Brunt

EXERCISE REFERRAL Started 1991 (Hailsham) Leisure instigated (Marketing ploy) 800+ schemes across UK (CIP, 2005) 16 Schemes in Wales? (14 Supported by NPHS) Early evaluations very promising. By 2001 Concerns leading to DoH Quality Assurance Guidelines (Unrealistic?) 2005 WAG guidance. 2006 NICE Guidance WAG launch National Programme.

EXERCISE REFERRAL Various models (Predominantly ‘Hailsham/ Oasis’), also multi-disciplinary teams, disease focussed (LIFT) & variations on the themes. Common Key features – 12 week intervention, Inclusion & Exclusion criteria, Leisure Centre/ Gym focus, Direct referrals initiated by GP’s/ Practice nurses, GPs carry out initial assessments, +/- Consent Forms Evidence suggests effective 6 – 8 weeks only. (NICE, 2006) What is ‘effectiveness’? – No’s of patients, retention, increases in physical activity, fitness, health gains, cost effective? Few robust research based evaluations.

THE EVIDENCE BASE The NICE guidance published in March 2006 provided 2 evidence statements: The evidence from 2 RCTs (1-) suggests that exercise referral schemes, involving a referral, either from or within primary care, can have positive effects on physical activity levels in the short term (6-12 weeks) However, the evidence from four trials (one 1++, three 1-) indicates that such referral schemes are ineffective in increasing physical activity levels in the longer term (over 12 weeks) or over a very long timeframe (over 1 year). A gap in the evidence base that they identified was the "Effect of follow-up on long term changes in physical activity. As a result of this the Public Health Interventions Advisory Committee (PHIAC) at NICE determined that there was insufficient evidence to recommend the use of exercise referral schemes to promote physical activity, other than as part of research studies where their effectiveness can be evaluated.

‘POSITIVE STEPS’ ERS £300k (BLF funded) multi-agency scheme established in Sept. 2004 Aims to provide physical opportunities to support the primary prevention of CHD amongst those at risk of developing the condition 12 week gym-based intervention Referrals from primary care (21/36 practices recruited), diabetes & cardiac rehabilitation clinics Referral criteria: inactivity, high cholesterol, hypertension, smoking, overweight/obese, family history, diabetes, insulin glucose tolerance (IGT) / insulin fasting glucose (IFG) Evaluation to assess the quality of the intervention (in terms of effectiveness, efficiency, equity and appropriateness)

RESULTS (1) 362 referrals between Sept. 04 and Mar. 06 Referral criteria broad, subjective and under reported. 17% of obese or overweight patients missed (based on known BMI measurements) Of all patients referred: - 53% (n=192) accessed, 10% (n=37) completed - Of the 10% completing, 4% (n=13) took out memberships - 13% (n=47) failed to start and 23% (n=82) dropped out On 23/10/06, 21% (n=75) had completed 12 week programme

RESULTS (2) Compliance decreased as time increased Patient compliance varied between delivery venues (scheme days/times) Qualitative feedback around medium & long-term lifestyle changes e.g. lost weight, feel better, confident, able to walk more & further Few patients recalled being offered advice about activities to do outside the scheme

RESULTS (3) At 12 weeks, average waist circumference reduction of 4.9cm (M) and 5.9cm (F) Suggests reduced risk of CHD & other chronic disease development 0/127 referrals from 7 practices overlapped with the 254 patients identified as being at a greater than 25% risk of developing CHD Cost effectiveness of scheme difficult to assess, but calculations suggest that scheme is not sustainable in long-term Logical to think that scheme may reduce burden on local services

HEARTLINKS Key Differences Patients seen at baseline, 1,3, 6 & 12 months (more if necessary) Direct Referrals (Primary & secondary care, smoking cessation, back to work programmes, community pharmacists, self-referral) & Mail-outs. All assessments & paperwork done by project officer (sports scientist) at initial consultation. Activity Programme ‘negotiated’ with patient includes home-based exercise, walking schemes, gentle exercise classes, aquafit, subsidised leisure passes (private & LA) – Progression inc. Mix & Match. All info relayed to GP for opportunity to veto. Economic Evaluation 12 month programme

HEARTLINKS - Assessment Stage of Change. Physiological: Ht, Wt, BMI, B/P, lipid profile (where provided). Cardiac Risk: Calmheart Scores (inc. pa levels) Physical Activity levels (Self-report & IPAQ) General Health (SF36) Reason for Referral

HEARTLINKS - Results 276 patients assessed: 246 patients accepted onto programme - 87 ‘dropped out’ (35%) 65 completed 12 months (so far). 13/13 Practices referring. 28% reduction in CHD risk (relative): 11% absolute risk reduction. 11 fold increase in physical activity (sustained OVER 12 MONTHS) Significant reduction in ‘Physical’ component of SF36 scores. Significant reduction in Systolic B/P BUT High support = Low recruitment rate & low turn over.

KEY ISSUES Two models explored: emerging evidence of scheme benefits Data collection/capture should be improved and standardised Importance of qualitative and quantitative information in determining medium and long-term consequences of scheme Patients can be supported in medium and long-term but need to balance quantity & quality Multi-agency – LA and primary care involvement is critical but schemes should not be wholly reliant on LA delivery Referrals should be targeted and prioritised (capacity issues) Patients should have choice of activities and be encouraged to use activities in everyday life, but issues around qualifications and regulation

WAY FORWARD (1) WAG randomised controlled trial: Positives WAG committed to tackling risk factors associated with chronic disease development across Wales. Inclusive – recognise that a multi-agency approach is needed. Committed to undertaking research to determine most effective approach and interventions. Committed to providing high quality endorsed training. Will significantly enhance existing skill & knowledge levels and capacity in leisure & exercise sector. Potential to dovetail into rehab agenda thereby re-orientating health services into community. RCT to assess one year adherence to activity depending on attendance at a 16 week ERS intervention or not. Proposed research extended from 6 UA areas to include all 22 in Wales, over 3 years.

WAY FORWARD (2) WAG randomised controlled trial: Negatives Concerns of study ‘contamination’ through proposed unit of randomisation being individual rather than practice. Practical impact with patients complaining when omitted from programmes. Ignores/ threatens relationships and structures established over many years and impact on linked programmes. Ethical issues – once eligible for referral and given consent to be in trial, patient still only 50% likely to receive intervention. Not providing a service which we know will benefit the patient. Unlikely that control patients will be able to access any other initiatives (based on their medical condition). Limited formal communication with experts. If a practice does not take part in the study, then they will NOT be able to refer patients onto their local scheme. Wrong question being asked (Is ERS ‘effective’ compared to handouts?). Evidence shows that ERSs are ineffective long-term. Danger that if it is badly designed it will at best show that a particular ‘model’ is ineffective or more likely unable to show anything because of confounding variables. Result ‘No future funding’.

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