The Effectiveness of Exercise Referral Schemes

Physical inactivity (PIA) is responsible for nearly 8% of non-communicable diseases worldwide and 1/6 of deaths in the United Kingdom (UK) (Cunningham et al., 2021; Katzmarzyk et al., 2021). In those who already have a chronic health condition, physical activity (PA) can improve all-cause mortality and disease outcomes yet nearly 40% of the UK population are currently inactive (British Heart Foundation, 2017; Lee et al., 2012). Exercise referral schemes (ERSs) were commissioned in the 1990’s as a solution to PIA but there has been considerable debate as to whether ERSs have been effective (National Institute for Health and Care Excellence (NICE, 2014); Hanson et al., 2020; Pavey et al., 2011). In order to ensure the schemes are effective, evidence supports the standardisation of delivery of the schemes. Without standardisation, there is a risk that they will be decommissioned, at a time where chronic conditions are rising, and a strong solution is required to reduce them.

What are exercise referral schemes; what is the purpose?

When a general practitioner or primary care team refers a patient to a supervised programme of PA, this is called an exercise referral scheme (Williams et al., 2007). The National Quality Assurance Framework (NQAF) was written in 2001 to provide guidelines for the effective use of ERSs (Department of Health, 2001). It was recommended within the guidance, that alongside PA interventions, schemes are most effective when paired with evidence-based behaviour change frameworks (Department of Health, 2001; Watson, 2017).

Are exercise referral schemes effective?

Early research supports efficacy of ERSs but there is concern as to whether they are effective in the short and long term (Fox et al., 1997; Pavey et al., 2011; Taylor et al., 1998). It has been argued that in real world scenarios, ERSs are ineffective because they have poor attendance and attrition rates and poor overall outcomes (Morgan, 2005; Pavey et al., 2011). Underlying these arguments however, is a lack of congruency in processes relating to ERSs such as: delivery of the schemes including training of PA providers and adherence to the NQAF; data capture and evaluation of the schemes; populations referred on to the schemes, programme specification, and inclusion or exclusion of evidence-based behaviour change techniques (Albert et al., 2021; Hanson et al., 2020).

In particular, Pavey et al., (2011) argued a potential case to remove investment for ERSs due to poor outcomes. One concern with this study however, is the study population: both chronically ill and healthy patients were included in the study. The trial did highlight the lack of standardised use of theory-based interventions and the impact this may have on outcomes but there also is a case to argue that chronically ill patients may achieve more positive outcomes. This is because they exhibit higher levels of motivation due to fears around their health status so including both populations within the study may have contributed to the lack of effectiveness of the schemes (Albert et al., 2020).

How do you measure the effectiveness of the scheme?

One of the challenges with assessing the effectiveness of ERSs is that the objectives must be clearly stated in order to assess whether or not they have been met by the scheme (Henderson et al., 2018). According to NICE (2014), the aim is to increase PA in those who have chronic conditions which could be considered a loose aim. Without agreeing on focussed objectives and how they should be measured it is impossible to assess the effectiveness (Hanson et al., 2020; NICE, 2014). If a scheme is delivered based on loose aims and without agreement on objectives or best practice, it is unlikely that they will be found to be effective.

Moreover, Buckley et al., (2020) found that many individuals who adhered to appropriate volumes of PA according to the UK PA guidelines (Davies et al., 2019), had low cardiorespiratory fitness. This means the volume of PA they were engaging in did not elicit the metabolic benefits associated with exercising at the optimal level of intensity. This is further supported by Gray et al., (2015) & Westcott et al., (2009). This highlights the importance of specialised exercise programmes to assist patients with engaging in clinically relevant intensities of physically activity. Therefore, continued commissioning via a thorough set of policies and objectives to ensure clinical best practice, must be a priority.

Conclusion

If physical activity is to reduce chronic conditions, it must be conducted at clinically relevant intensities. It has been argued that ERSs are ineffective at increasing physical activity. However, it is clear that there is no standardisation of who the schemes are delivered for, how they are studied for effectiveness and how they are delivered. Before making an assessment on the effectiveness of schemes, commissioning groups must make it a priority to standardise the delivery of schemes because ultimately, if delivered effectively, they may be the key to decreasing numbers of non-communicable diseases.

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