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What Are Exercise Referral Schemes?

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Exercise referral schemes (ERSs), also known as exercise on prescription, are equivalent to Exercise is Medicine® in the United States. ERSs were established in the early 1990s (1), with aims to reduce physical inactivity within specific clinical populations who are referred for the management and treatment of specific health conditions (2). ERSs are promoted through primary care settings, usually through visits to the general practitioner (GP). ERSs are a low/moderate-risk provision aligned with a prevention model, which therefore excludes unstable or high-risk individuals who may be better suited to other exercise rehabilitation pathways (3).

Importance of ERSs to Public Health

ERSs play an important role within public heath, as schemes can provide a lower-cost, more accessible, more user-friendly mechanism of support in maintaining and improving health through exercise compared with a clinical-based exercise program. At present, the aging population is intensifying globally, which is placing increased pressure on health systems, including the UK’s National Health Service (NHS) (4). This increase in demand for health services, which also stretches resources, makes it important to find innovative, holistic ways to manage health conditions other than through high-cost medical interventions. ERSs can help to fill this void by providing a clinical exercise intervention in a local, nonclinical environment such as a leisure center, gym, or community hall. This approach tends to reduce both the participant cost and the participant access burden.

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The exact number of ERSs within the UK is currently unknown; however, schemes exist across England, Scotland, Wales, and Ireland. Pavey et al. (2) suggested that there were 600 schemes across the UK, but a systematic mapping effort is needed to confirm this estimate.

AIMS OF ERSs

The main aim of ERSs is to manage and treat specific health conditions using supervised exercise over a set period. Schemes typically cover a 12-week personalized program of both aerobic and resistance exercise in a safe, stable environment. Schemes also are designed to include social support, which in theory should encourage long-term physical activity (PA) participation (2,5,6). Although providers are asked to provide referrals with a personalized ExRx, there tends to be considerable inconsistency with this request, particularly across the different chronic conditions that warrant a referral. As a result, personalized, individualized programs are usually left to the exercise specialist to design and, therefore, may not provide optimum improvement in health for the patient.

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Recently published NHS plans (7) include a goal to reduce the public health burden of care through an emphasis on individual self-care management, which was a key priority of past NHS plans (7–9). Using exercise to self-care manage long-term chronic conditions or noncommunicable disorders (NCDs), such as diabetes, cancer, cardiovascular disease, and respiratory diseases, could reduce the burden on GPs, disorder-specific specialists, and services within the NHS, as NCDs account for 89% of deaths in the UK (10). ERSs also can empower individuals, providing the knowledge of how to be physically active and reduce both the impact and the risk of these chronic health conditions, with ERSs being a prominent form of treatment and/or prevention (11).

EXERCISE REFERRAL PROCESS

Models of UK ERSs vary from scheme to scheme. At present, there is no set model that all ERSs should follow. Regardless of the model implemented locally, referrals are typically made by primary care professionals, such as GPs, nurses, and disorder-specific specialists. The usual exercise referral process can be seen in Figure 1. The NICE guidelines, or PH54: Physical Activity: Exercise Referral Schemes (5), detail the inclusion and exclusion criteria, along with complete contraindications that the primary care professional must adhere to when making an ERS referral.

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Figure 1:

The exercise referral process.

ERS GUIDELINES

The NICE Guidelines are the most recent policy on how ERSs could be designed, implemented, and evaluated within the UK. This guidance was intended to give exercise providers and instructors, policy makers, and commissioners the evidence to support ERSs and guidance on how to implement schemes (5). However, these guidelines still lack specifics in many areas, including a lack of descriptive information regarding support for specific activities, type/mode of exercise, scheme duration, and disorder-specific activities, which produce the optimum health outcomes for those who adhere to the scheme.

NICE has, however, provided several recommendations for future research to improve schemes, including research examining the outcome and cost effectiveness of different types of ERSs. This would include looking at scheme characteristics, settings, intensity, duration, techniques used, and populations enrolled. Other factors to consider would be those that encourage scheme uptake and adherence, and program design, program content, program delivery, and choice of activity. With proper time to study these factors, better developed ERSs will likely evolve and help transform chronic disease management across the UK from provider-based to self-care.

CURRENT ISSUES WITH ERS GUIDELINES

The most recent ERS research has begun to show that schemes are effective in producing positive health outcomes. Although the most optimal scheme length has not yet been determined, the early evidence seems to indicate that scheme durations of just 12 weeks can produce changes in PA levels. This 12-week duration is the most common length of scheme in the UK, resulting in PA changes occurring through participation in, or an increase of, moderate to vigorous PA, and a concomitant reduction in daily sitting time (6).

Schemes also have the freedom to report and measure any outcomes they wish, and there are no specific measures that the NHS, NICE, or any other organization require to be used by every scheme. This lack of uniformity presents challenges in trying to determine efficacy or when looking to compare scheme outcomes.

Because of the lack of uniformity across the UK, many different types and modes of exercise schemes exist, with design, implementation, and outcome measures often dependent on local funding, available equipment, environment, and/or instructor’s experience. The various ERS activities that have been reported within the UK include gym-based exercise, group exercise classes, walking, gardening, golf, and swimming. Also, although scheme length tends to be 12 weeks, various lengths have been reported, ranging from 8 to 52 weeks, with schemes of shorter and longer lengths having positive effects on condition-specific outcomes (6). It was found that schemes of 8 weeks can provide significant reductions in blood pressure (12), but schemes of longer length (20+ weeks) can provide further improvements in blood pressure and body mass index simultaneously (13), along with improving PA levels, adherence to exercise prescribed, and support for longer-term adherence to exercise (14).

NATIONAL REFERRAL DATABASE

Because there have not been any specific guidelines on how to collect and store exercise referral data, there was previously no national ERS database to review. In 2016, the National Referral Database (NRD) was developed to provide a platform for exercise providers to upload all their respective ERS data, and now there is a national database available, for a fee, to all UK ReferAll providers. At present, the database has approximately 120,000 patients from 69 ERSs in the UK. The future aims of NRD are to provide a platform with a set of measures that all providers must collect and upload and to provide an open data source that is available for researchers to examine in the hopes of continually improving ERSs.

MOVING FORWARD: THE FUTURE OF ERSs

Going forward, ERSs can only improve if providers pursue all the NICE recommendations for further research (5). Taking this important step will provide the opportunity to learn from current schemes what is working and what needs to be improved. An equally important step in this process is to ensure that ERS professionals have the proper training (databases, evaluation, providing more effective prescriptions) to maximize individual health benefits, to reduce dropout rates/increase adherence, and to collect accurate data for future analysis. Only by having this type of systematic approach can the full potential of ERSs be realized.

SUMMARY

ERSs in the UK are a beneficial intervention in promoting PA and managing long-term health conditions and NCDs. It is vitally important to continue widening the evidence base to further support the use of ERSs, which will then provide the impetus for updating the NICE guidelines. With sufficient data in the future to show short- and long-term efficacy, ERS programs could become a global model for self-managed care.

References

1. Department of Health. Exercise Referral Systems: A National Quality Assurance Framework. London: Department of Health. 2001 [cited 2019 May 23]. Available from: https://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009671.

2. Pavey TG, Taylor AH, Fox KR, et al. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ. 2011; Nov 4;343:d6462.

3. Henderson H, Evans A, Allen-Collinson J, Siriwardena N. The ‘wild and woolly’ world of exercise referral schemes: contested interpretations of an exercise as medicine programme. Qual Res Sport Exerc Health. 2018;10(4):1–19.

4. Bauman A, Merom D, Bull FC. Updating the evidence for physical activity: summative reviews of the epidemiological evidence, prevalence and interventions to promote active ageing. Gerontologist. 2016;56(Suppl 2):S268–80.

5. NICE Web site [Internet]. Physical Activity: Exercise Referral Schemes (PH54), London: NICE. 2014 [cited 2019 May 23]. Available from: https://www.nice.org.uk/guidance/ph54.

6. Rowley N, Mann S, Steele J, Horton E, Jimenez A. The effects of exercise referral schemes in the United Kingdom in those with cardiovascular, mental health, and musculoskeletal disorders: a preliminary systematic review. BMC Public Health. 2018;18:949.

7. National Health Service. The NHS Long Term Plan. [Internet] 2019 [cited 2019 May 3]. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf.

8. Department of Health. The NHS Improvement Plan: Putting People at the Heart of Public Service. London: Department of Health. [Internet] 2004 [cited 2019 May 23]. Available from: https://navigator.health.org.uk/content/nhs-improvement-plan-putting-people-heart-public-services-2004.

9. Department of Health. Self Care—A Real Choice. London: Department of Health. [Internet] 2015 [cited 2019 May 23]. Available from: https://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4100717.

10. World Health Organization. Non-communicable diseases (NCD) Country Profiles. [Internet]. 2014 [cited 2019 March 14]. Available from: http://www.who.int/nmh/countries/gbr_en.pdf.

11. Carmichael AR, Daley AJ, Rea DW, Bowden SJ. Physical activity and breast cancer outcome: a brief review of evidence, current practice and future direction. Eur J Surg Oncol. 2010;36(12):1139–48.

12. Webb R, Thompson JES, Ruffino J-S. Evaluation of cardiovascular risk-lowering health benefits accruing from laboratory-based, community-based and exercise-referral exercise programmes. BMJ Open Sport Exerc Med. 2016;2(1):e000089.

13. Dugdill L, Graham RC, McNair F. Exercise referral: the public health panacea for physical activity promotion? A critical perspective of exercise referral schemes; their development and evaluation. Ergonomics. 2005;48:1390–410.

14. Tobi P, Estacio EV, Renton A, Foster N. Who stays, who drops out? Biosocial predictors of longer-term adherence in participants attending an exercise referral scheme in the UK. BMC Public Health. 2012;12:347.

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