1. Welcome to this presentation on Let’s Get Moving
My name is ……………………………….. and I’m from …………………………….
I’m going to talk through this presentation on Let’s Get Moving, which covers:
the importance of physical activity for health
the cost to the NHS
the evidence based solution and commissioning principles
There will be an opportunity for questions at the end of the presentation.

2. Importance of being active
The benefits of regular physical activity are clearly articulated:
for adults, achieving 150 minutes (2 ½ hours) of at least moderate intensity physical activity over a week
Comparable benefits can be achieved through 75 minutes of vigorous exercise throughout the week
helps prevent and manage over 20 chronic conditions including coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal conditions
We know that Physical Activity, or inactivity, can have a major impact on both the prevention and management of chronic disease. The importance of being active is documented in detail in the CMO report Start Active, Stay Active (2011)
In detail:
Physical inactivity is the fourth leading risk factor for global mortality (6% of deaths nationally)
Has a substantial impact on the risk of major non-communicable disease: including coronary heart disease (CHD), hypertension, type 2 diabetes, and some cancers.
Can reduce the risk of stroke, be used to treat peripheral vascular disease and to modify CVD risk factors, such as, high blood pressure and adverse lipid profiles.
Protects against cancers of the colon, breast (post menopause) and endometrium
Reduces the risk of and helps manage musculoskeletal health conditions, including osteoporosis, back pain and osteoarthritis.
Reduces the risk of depression and promotes many other positive mental health benefits, including reducing state and trait anxiety, improves physical self-perceptions and self esteem, and can help reduce physiological reactions to stress.
Has been found to be just as effective in the treatment of mental ill health as anti-depressant drugs and psychotherapy.
Supports weight management - physical activity by itself can result in modest weight loss of around 0.5kg-1kg per month. 2

3. What does this look like?
Only 39% of men and 29% of women are currently meeting the CMO recommendations for physical activity
That’s 27 million people in England alone who are not active enough to benefit their health
The NHS spends £3,000 every minute on combating illness, which could be prevented by increased physical activity
A modest increase in physical activity amongst older people could cut hip fractures by one per cent, saving the NHS more than £200 million a year.
A 20 per cent increase in cycling would save the NHS more than £50 million in treatments.
So how active are we?
Based on Health Survey for England 2008 (HSE 2008) self-reported physical activity, only 39% of men and 29% of women aged 16 and over met the Chief Medical Officer’s (CMO) minimum recommendations for physical activity in adults. The percentages of both men and women who met the recommendations generally decreased with age. (This is based on amended self-reported HSE questions)
Using the old methodology has seen a further rise in the percentage of adults saying that they meet the current physical activity guidelines. The 2008 figures for men and women were 42% and 31% respectively, up from 40% and 28% in 2007 and 32% and 21% in 1997.
However, based on HSE 2008 accelerometry measure, only 6% of men and 4% of women met the CMO’s recommendations for physical activity.
That’s 27 million people in England alone who are not active enough to benefit their health.
As we know, health inequalities are of critical importance to the NHS and in physical activity there are significant inequalities:
Physical activity is higher in men at all ages
Physical activity declines significantly with increasing age for both men and women
Physical activity is lower for BME groups, with the exception of African Caribbean and Irish populations.
Low income household groups are less active compared to high income household groups
What does this actually mean in terms of peoples quality of life?
Of adults aged over % are not able to walk outside on their own, and 9% cannot manage stairs unaided
By the age of % women and 7% men do not have sufficient leg strength to get out of a chair without using their arms
The return on investment for blood pressure, cholesterol, diabetes, COPD, mild/moderate mental health, low back pain and V02 max (fitness – which can have a significant impact on acute care outcomes, for example, recovery time post operative care and length of hospital bed stay) can be accrued within 12 weeks. 3

4. Why commission Let’s Get Moving?

5. Making the case
NICE fully endorses the importance of physical activity as a means to promote good health and prevent disease (NICE 2006 PH2)
NICE endorses brief interventions in physical activity as being both clinically and cost-effective for delivery by the NHS in primary care. (NICE 2006 PH2)
Around one in four people in England say they would be more active if they were advised to do so by a GP or nurse. (HSE 2007)
54 per cent of patients said that their GP had not provided advice on diet and exercise. (Lord Darzi's NHS Next Stage Review Final Report)
In 2006 NICE published public health guidance 2: four commonly used methods to promote physical activity, and endorsed brief interventions in physical activity as being both clinically and cost-effective in the very long term for delivery by the NHS in primary care.
However, what we also know there is a real lack of knowledge and understanding by health care practitioners as to what physical activity for health recommendations are, and how to raise the issue of physical inactivity with patients.
This issue has been reflected in the Lord Darzi’s ‘NHS Next Stage Review Final Report’, where it identifies that 54% of patients report not being given lifestyle advice by primary care practitioners.
However, one in four people in England say they would be more active if they were advised to do so by a doctor or nurse.
Given there are 185 million GP consultations every year, this presents an enormous opportunity within primary care to promote physical activity.
REFERENCE
National Institute for Clinical Excellence (2006) PH 2: Four commonly used methods to increase physical activity 5

6. The Evidence
According to NICE PH guidance 2, primary care practitioners should:
using a validated tool (GPPAQ), identify inactive adults
advise them to aim for the amount of activity outlined in the guidelines
take into account the individual’s needs, preferences and circumstances
agree goals with them
provide written information about the benefits of activity and the local opportunities to be active
Specifically, the NICE Guidance states that, primary care practitioners should take the opportunity, whenever possible to:
use the validated tool (GPPAQ), to identify inactive adults, advising patients to aim for 30 minutes of moderate intensity activity on 5 days of the week (based on existing guidelines for physical activity). Also using their judgement to determine when this patient advice would be inappropriate.
take into account the individual’s needs, preferences and circumstances; agree goals with them; and provide written information about the benefits of activity and local opportunities to be active.
to follow patients up at appropriate intervals e.g. over a 3 to 6 month period.

7. Brief interventions
Following a review of the extensive evidence on lifestyle change, NICE recommended the delivery of brief interventions that help people to:
understand the likely impact of their behavior on their health
feel positive / optimistic about changing their behaviour
make a personal commitment to change
set goals to undertake specific actions over a specified time
plan changes in terms of easy steps
plan for events or situations that might get in they way of change
share their behaviour change goals with others
What does this mean for front line health care staff?
In 2007 NICE released guidance on behaviour change (PH6) – in conjunction with NICE guidance PH2 relating to brief interventions, this this informs us that an effective Brief Intervention should to comprise of:
understand the likely impact of their behaviour on their health
feel positive / optimistic about changing their behaviour
make a personal commitment to change
set goals to undertake specific actions over a specified time
plan changes in terms of easy steps
plan for events or situations that might get in they way of change
share their behaviour change goals with others

8. Lets Get Moving
When the NICE public guidance endorsing brief interventions in primary care was published, the response from PCTs and primary care was: how can we implement this?
The Department of Health’s response was to lead on the development of Let’s Get Moving, a new physical activity care pathway

9. Introducing ‘Lets Get Moving’
a behaviour change programme that incorporates a Physical Activity Care Pathway based on recommendations of the NICE Public Health Guidance 2 & 6
LGM is designed to assist practitioners in guiding inactive adults aged towards gradually become more active, for the prevention and management of chronic disease
has proven feasible for delivery by practitioners working in primary care settings.
To give you a quick overview:
Let’s Get Moving is a behaviour change programme, which incorporates a clinical care pathway for physical activity, designed to help inactive adults aged 16–74 to become more active, and is based on the recommendations of the 2006 NICE guidance PH2, and 2007 NICE guidance PH6, plus, learning from best practice, including exercise clinics from the Local Exercise Action Pilots.
The LGM intervention has been developed to include support tools such as training, to enable practitioners to effectively deliver a physical activity brief intervention that will support the patient to change their behaviour.
This care pathway for physical activity can be utilised by service deliverers to systematically recruit appropriate patients (for example, weight management clinics, cancer survivorship 6 month follow up, NHS health check) and screen for inactivity using the validated questionnaire GP Physical Activity Questionnaire (GPPAQ).
Patients identified as not meeting the CMO’s recommendations for physical activity are offered a brief intervention drawing on motivational interviewing techniques, which takes a patient-centred approach to:
highlighting the health benefits of physical activity;
working through key behaviour change stages; and
concluding with a clear physical activity goal set by the patient, identifying local activity-based opportunities, including exercise on referral schemes where appropriate.
Following the brief intervention, participating patients should be followed up over regular intervals, at least at 3, 6 and 12 months, to check patient progress, encourage and reset activity goals.
LGM has been positively evaluated in a trial in 14 GP surgeries, delivered by GPs, practice nurses and health care assistants. The trial demonstrated LGM’s feasibility for implementation in the NHS.

10. Local priorities
LGM presents important commissioning opportunities for
a new Public Health Service
LGM will help to drive public health outcome indicators and
reduce health inequalities caused by physical inactivity
LGM supports delivery of public health initiatives, such as:
NHS Health Check
Long term conditions
LGM as a commissioning opportunity for primary care trusts, reflects the values of QIPP, with the aim of developing evidence-based programmes that respond to the needs of local people, including tackling health inequalities.
In addition, commissioning LGM provides a clear opportunity for Public Health and GP consortia to deliver health outcomes
LGM offers a real opportunity for the NHS to work with local authority and 3rd sector partners to ensure that appropriate physical activity opportunities are available.
The patient pack should include a wide variety of physical activity and sport opportunities for people new to physical activity – linking into existing local services and networks
Such as walking groups, led cycle rides, dance, swimming, leisure centre based classes 10

11. This slide features a schema of the LGM physical activity care pathway process. The following slides go through this process in greater detail
Suggestion: Have a print out of this schema available for attendees so when talking through slides 12 to 18, the schema can be followed

12. Step 1. Recruit Recruitment methodology decided at a local level
Flexible entry route:
New Patient Registration
Health Check
Diabetes Clinic
Disease Registers
The first stage of the LGM care pathway is recruitment.
Recruitment can be very flexible and is something that can be set locally and linked to any commissioning requirements.
You may wish to identify specific target groups through existing or established mechanisms or, you may wish to develop a separate entry mechanism that triggers the pathway. For example, linking the pathway to prevention services such as NHS health check, weight management services or a diabetes clinic.
In the feasibility trial for LGM, recruitment from disease registers including hypertensive and diabetes proved positive. Patients with these conditions also represent a quick return on investment (of 12 weeks) if they become more active. 12

13. Step 2. Screen Assess physical activity levels using the GPPAQ
This classifies people into one of four categories:
Inactive
Moderately inactive
Moderately active
Active
Step 2 in the LGM delivery process is the Screen stage, whereby the patient completes the General Practice Physical Activity Questionnaire (GPPAQ) (either self completion or with assistance).
Demonstrate GPPAQ (using the excel spreadsheet)
The GPPAQ is a validated questionnaire, linked to CVD risk and all-cause mortality, used to assess how active adults aged are and whether they require a brief intervention.
The GPPAQ classifies patients into a physical activity category, collectively known as the Physical Activity Index (PAI). The classifications are broken down into the following categories:
inactive;
moderately inactive;
moderately active; and
active.
Patients classified as not being active (therefore inactive to moderately active) are offered an LGM brief intervention. This can be completed immediately, or the patient can be offered a separate consultation either with the same practitioner or a different one.
Patients classified as active – that is, patients who already complete at least 30 minutes of at least moderate intensity activity on five or more days per week should be encouraged to remain active and exit the care pathway (based on existing guidelines).
Please note, although the GPPAQ asks questions specifically about walking, DIY, housework and gardening, these activities are not included in the Physical Activity Index calculation due to significant over report during validation. Reducing the accuracy of the physical activity outcome and also the correlation with CVD risk.
However, practitioners can still question patients to establish the level of intensity relating to walking activity, and if this is deemed sufficient in meeting the CMO’s recommendation, there is a read code which can be used: “30 minutes a day of at least moderate intensity walking on five or more days of the week”
The GPPAQ is available in both word and excel (which includes the embedded algorithm). Explain that read codes are available for primary care to record GPPAQ results on patient records, and that the algorithm is being embedded into the majority of GP software systems including EMIS and Informatica Systems, contact your software provider to see whether this feature is available.
For more information relating to the GPPAQ, please refer to the Let’s Get Moving section on the Department of Health website

14. Step 3. Intervene Telling people what to do can sometimes be helpful
The spirit of the approach
Telling people what to do can sometimes be helpful
However, in health behaviour change, a telling approach can sometimes get in the way
Evidence suggests that adopting a “guiding style” can be more effective and helpful in motivating people to think about, start and persist with lifestyle change
Lets Get Moving takes a motivational interviewing approach
Step 3. Intervene
Now we know the key principles for a successful brief intervention (as outlined by NICE PH6), and we also know that in primary care settings we frequently find practitioners need to take a more directive / telling style.
This directive approach is very beneficial for certain behaviours, for example, showing someone how to use an asthma inhaler for the first time, or telling an individual when or how frequently their medication should be taken.
However, when trying to address complex health behaviours taking a telling or directive approach can often get in the way. This is why Let’s Get Moving has adopted a motivational interviewing (MI) approach to deliver the intervention, and MI is something that practitioners delivering the LGM will be trained in.

15. Step 3. Intervene cont’d
The practitioner, skilled in the use of motivational interviewing principles follow initial steps to guide the patient towards one of the following options:
Patient decides to do nothing further and so leaving the pathway
Patient chooses to become more active and sets a personal physical activity goal
Patient chooses to have a more in-depth motivational interview about physical activity with a trained MI practitioner.
The initial practitioner and patient discussion we have just seen is very important - it lays the foundations for behaviour change, and given that the discussion can be undertaken in a short period of time, we recommend that an appropriate health care professional should deliver the ‘Intervene’ element of Let’s Get Moving.
At the end of the initial LGM intervention steps, the patient will be in a place where they need to make a decision about what they intend to do next. The patient may choose one of the 3 following options:
Option A, the patient may be very reluctant and resistant to change and not want to go any further. In this instance, it would be considered that the patient leaves the pathway, but that the door is left open for them. If they wish to come back and re-engage in the process, they are welcome to do so.
Option B, as with Gail, in the initial steps the practitioner may be able to get the patient to set a physical activity goal, therefore, the patient would move on to stages 4 and 5.
Option C, the patient may be reluctant but interested, therefore, the patient may require a longer discussion with a practitioner skilled in Motivational Interviewing. Therefore, the patient would be invited back for a longer discussion with a qualified practitioner, within the surgery, then they would move onto stages 4 and 5. 15 15 15

16. LGM patient support pack
Intervene options b or c.
Patient is provided with a Let’s Get Moving
patient support pack, which includes:
Motivational interviewing exercises
Goal setting sheet
Customised insert featuring local physical activity opportunities
Patients choosing options B or C should be given an LGM patient pack. [show pack]
The pack has been developed and trialled in the feasibility study. The core content incorporates motivational interviewing exercises which the patient can also then revisit outside the consultation.
At the back of the LGM patient pack you will see a range of inserts:
There is one for ‘goal setting’, where the patient can record their physical activity goal/s.
There are two further indoor and outdoor activity inserts which can be customised to reflect local information. Insert templates and instructions for completion can be downloaded on DH website.
It is also useful to insert any existing literature, walking maps are particularly useful resource for patients
The LGM patient pack has been developed to support and reinforce the brief intervention with the patient. The pack provides the practitioner and patient with information on local physical activity provision. Therefore, depending on conversation that takes place, the practitioner can take the opportunity to signpost the patient (depending on what activities the individual has expressed an interest in), for example, to: local swimming lessons, local walking groups, local cycling programmes etc. An online local activity search tool is available at: nhs.uk/letsgetmoving
The goal setting stage is where the practitioner may realise that the patient is eligible for services that are only offered to individuals meeting certain criteria set by the commissioner, for example, exercise referral, falls prevention or physiotherapy that the patient may require to enable them to become more active. If the patient is eligible, for example, exercise referral, the practitioner may wish to make the patient aware of the service as they set their activity goal.

17. Step 4. Active participation
Following a brief intervention there is about a 12 week period where the patient gradually becomes active on their own
Patients may need to be followed up more regularly than this
Some patients may benefit from extra support during this time, for example by a health trainer
Following options B & C, the next step for patients is Stage 4 – ‘Active Participation’. This is a 12 week period that does not require an further direct input from the practitioner. This is the time where the patient goes away and undertakes their physical activity goal.
This is where it is important for commissioners to have worked with local partners including 3rd sector and the County Sports Partnership to ensure that there are a wide variety of appropriate physical activity opportunities available
In the LGM feasibility trial the majority of patients chose to undertake self directed activity including using pedometers and the walking map provided, only 1% of patients were eligible for and opted for an exercise on referral programme.

18. Step 5. Review
It is recommended that the patient is followed up at regular intervals, for example 3,6 and 12 months
The NICE guidance says patients should be followed up at regular intervals over 3 and 6 months
The GPPAQ requires annual completion
It is recommended that the patient is followed up at regular intervals, for example 3,6 and 12 months, these should be delivered by the person who carried out the brief intervention.
During the review intervention, the practitioner will again move through stages 2 and 3. Using their MI skills, the practitioner will respond to difficulties the patient may have experienced, or reassure and encourage them to sustain their behaviour change.
The review interventions are where the patient may wish to explore further physical activity opportunities that where not discussed in the original consultation, therefore, the LGM patient pack can enable the practitioner to sign post patients to local opportunities that may be of interest and new to the patient.

19. Feasibility pilot

20. Summary of findings
526 adults were screened, of which 86% were found to be less than active and 83% were interested in becoming more active
315 attended the LGM brief intervention, of those, 54% were from black and ethnic minority groups
The LGM brief intervention took between 3 to 21 minutes to complete
Patients who attended the follow up intervention, 62% self reported an increase in their physical activity levels
Also at the follow up intervention, 59% of adults reported undertaking self-directed outdoor activities e.g. walking.
Summary of findings from the feasibility trial
14 GP surgeries participated in the feasibility trial, which was carried out in two waves. The first tranch of practices informing the implementation for the second wave of practices.
The intervention was delivered by GPs, Practice Nurses and Health Care Assistants. Health care professionals either assessed physical activity levels and delivered the brief intervention straight away or they carried out the initial assessment and then signposted to another practitioner in the surgery to deliver the full brief intervention. Patients were either recruited off disease registers or opportunistically.
The data in this slide reflects the quantitative data from the second group of GP surgeries
Areas of interest:
The prevalence of inactivity in the populations accessing primary care services was considerably higher than the inactivity prevalence levels of the general population – 86% of those screened were classified as less than active.
The feasibility study demonstrated that it does not aggravate health inequalities, with 54% BME groups engaging, there was also a roughly equal split between men and women engaging as well as across age groups.
The intervention took between 3 & 21 minutes to deliver. Practitioners used the time that they had available to them to deliver the intervention, those recruited opportunistically the intervention took between 3 & 10 minutes and those recruited through the disease register a longer consultation time was set aside and the brief intervention took up to 20 minutes.
Of the patients attending the 3 month follow up 62% reported that they had increased their activity levels and 59% identified that the way they had done this was via self-directed outdoor activities, mainly walking using pedometers and walking maps. Only 1% attended Exercise on Referral schemes.

21. Commissioning Let’s Get Moving
What are some of the considerations for implementing this model locally?

22. Commissioning Let’s Get Moving
It is up to each commissioner to decide whether they want to commission LGM to meet their:
communities’ health needs (JSNA) and
Local priorities including those identified through the public health outcomes framework
In commissioning LGM, commissioners will stipulate the model used, who will provide the service, and who the service is open to and then how they plan to monitor the service
It is up to each commissioner to decide whether they want to commission LGM to meet their communities’ health needs (JSNA) and local priorities (for example PHOF)
In commissioning LGM, commissioners will stipulate the delivery model used, who will provide the service, who the service is open to and then how they plan to monitor the service.
LGM can be used across the NHS from primary care to the acute sector for the prevention and management of chronic disease and improve outcomes of acute care. It is a flexible model that can be adapted for use in different settings and delivered by a range of professionals.

23. Commissioning Let’s Get Moving cont…
To commission LGM, the commissioner should ensure the following:
Appropriate service provider commissioned to target specific population
Service providers are appropriately trained to deliver Lets Get Moving
The patient pack is available with local activity inserts completed for the service provider to give to patients
The service provider is the appropriately supported and monitored
There is comprehensive commissioning guidance, available on the DH website that can be used to assist with the commissioning LGM in your area. When considering commissioning LGM, ensure that
An appropriate service provider commissioned targets specific population
Link to other appropriate health initiatives such as NHS Healthcheck
Service providers are appropriately trained to deliver Lets Get Moving
There are two training modules, the first on physical activity for health and a comprehensive overview of the care pathway and the second on motivational interviewing.
All those involved in delivering LGM must complete module one. It is possible for a practitioner to screen for inactivity and then signpost on for a brief intervention. The person who is delivers the brief intervention must also complete module two or already be an experienced MI practitioner.
The LGM patient pack is available to order via the Department of Health and the local activity inserts can be downloaded and completed then distributed to the service providers to give to patients.
The service provider should be appropriately supported and monitored.

24. Partner opportunities for LGM
LGM offers a real opportunity for partnership working to ensure that appropriate physical activity opportunities are available.
The patient pack should include a wide variety of physical activity and sport opportunities for people new to physical activity
Such as walking groups, led cycle rides, dance, swimming, leisure centre based classes
LGM offers a real opportunity for partnership working with the local 3rd sector partners and county sports partnership to ensure that appropriate physical activity opportunities are available.
As a result the patient pack should include a wide variety of physical activity and sport opportunities for people new to physical activity such as walking groups, led cycle rides, dance, swimming, leisure centre based classes, exercise on referral
Notes about exercise on referral
It is important to note that LGM has not been designed to replace exercise on referral or any other prescription based condition specific schemes. Instead, exercise on referral should be an exit route from the care pathway for those who clinically need and want to attend these schemes
Although NICE does not endorse the use of exercise on referral schemes for the general promotion of physical activity (NICE, 2006, Four commonly used methods to promote physical activity).
NICE does advocate the use of exercise on referral for certain conditions, including:
Low back pain (NICE Clinical Guideline 88, 2009);
Management of chronic obstructive pulmonary disease in adults in primary and secondary care (NICE Clinical Guideline 12, 2004);
Depression: Management of depression in primary and secondary care (NICE Clinical Guideline 23, 2004); and
Occupational therapy interventions and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care (2008).

25. Further information on delivery
For further information about Let’s Get Moving, visit: and search for Let’s Get Moving
You will find details of:
LGM commissioning guidance
LGM patient support pack
GPPAQ
LGM feasibility study
LGM training information
NHS choices physical activity search tool for local opportunities
queries to:
Details of LGM supporting materials are available to view and download from the Let’s Get Moving section on the Department of Health website, and can be ordered via the DH orderline

26. Questions
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