Is Exercise Referral fit for a new decade?

Posted by Coral Hanson, Emily Oliver, Caroline Dodd-Reynolds and Paul Kelly

“Exercise referral doesn’t work”. We have heard this said time and time again, particularly by those who are peripherally aware of the field, but perhaps most worryingly by commissioners and those involved in public health policy. We’ve argued that this is simply not true. A different interpretation is that the exercise referral evidence-base, and the way it is used, hasn’t been working.

The term ‘exercise’ conjures images of Mr Motivator-style aerobics in eye-searing 1990’s lycra

Exercise referral is a decades-old process where professionals in primary care (GP/practice nurse) or secondary care (specialist doctor/physiotherapist) refer patients to a community-based physical activity scheme - often delivered by a leisure provider. National policy guidance (NICE, 2014) recommends that referrals are made where a patient is otherwise inactive or sedentary (both different parameters and not simple to classify in a primary care setting such as a GP surgery) and additionally has an existing health condition, or is at risk of having one.

Traditional evidence-generation for exercise referral has tended to be single-site studies that are then condensed using systematic-review-based methods. Given the considerable variation in how schemes are designed, delivered and evaluated at local level, this is problematic. Vague policy guidance and limited evaluation funding means that most scheme iterations are unsuitable for inclusion and interpretation in this outcome-driven way (Oliver et al., 2016). Collectively, the findings of such overviews are rather underwhelming.

Consequently, during times of tightened public health spending and commissioning, many UK exercise referral schemes have been de-commissioned. This seems misguided, given evidence that some schemes work, for some individuals, in some contexts. Understanding these nuances is at odds with the ‘best practice’ and ‘scaling-up’ that is so often seen as desirable within physical activity policy. Evidence must (and thankfully is starting to) account for consideration of local tailoring and best fit for a given community. Incorporating such evidence into policy is a different matter, of course.

To assist with collating evidence that can meaningfully inform policy and commissioning decisions in this area, our recent editorial in the British Journal of Sports Medicine proposes a sea change in how exercise referral is considered, categorised and reported. The term ‘exercise referral’ is outdated in 2020. ‘Physical activity referral schemes’ more appropriately describes the innovative and extensive range of programmes being delivered, and allows for other types of referral including self-referral, social prescribing and group-based needs assessments, to potentially contribute to the evidence base.

Personally, we’re not keen on the term ‘exercise’; it conjures images of Mr Motivator-style aerobics in eye-searing 1990’s Lycra. It sounds so imposed and constrained

You may have noticed we have replaced ‘exercise’ with ‘physical activity’ – surely a more inclusive term for what is ultimately a behaviour – and one which we are trying to change. Traditionally exercise referral schemes were mainly gym-based and we think that this image probably persists when we think of exercise referral today. Personally, we’re not keen on the term ‘exercise’; it conjures images of Mr Motivator-style aerobics in eye-searing 1990’s lycra. It sounds so imposed and constrained. Even a simple phrasing change can have far-reaching implications, and hopefully for the better in this case.

In the editorial, we propose a simple way of identifying, classifying, and recording key information about physical activity referral schemes that will enable better understanding of what exists and what is working. Our new reporting checklist (or taxonomy) encompasses all physical activity schemes that:

1. have the primary aim of increasing physical activity,
2. have a formalised referral process, 
3. are provided for individuals who are inactive/sedentary, and/or have or are at risk of a health condition. 

The classification framework can be seen in figure 1 (below). The full reporting checklist can be found in the editorial. We propose that this be used by commissioners, practitioners and researchers alike: for auditing and monitoring, to capture service delivery and in generation of evidence reviews.

Figure 1

We are very keen to hear from anyone working in exercise/physical activity referral of any kind as we move forward with refining this idea. The model was proposed to policy-makers, practitioners and academics at a consensus event in late 2019, and we are currently refining it by undertaking a Delphi Survey. We are inviting further comment, critique and engagement to make the final version as accessible and ‘fit for purpose’ as it possibly can be, so please get in touch with Coral, Caroline, Paul, or Emily via twitter or email - details below.

Coral Hanson, Research Fellow, Edinburgh Napier University @HansonCoral / C.Hanson@napier.ac.uk

Emily Oliver, Associate Professor, Director of Research in the Department of Sport and Exercise Sciences, Durham University @_EJOliver

Caroline Dodd-Reynolds, Associate Professor, Department of Sport and Exercise Sciences, Durham University @carolinedod / caroline.dodd-reynolds@durham.ac.uk  

Paul Kelly, Lecturer in Physical Activity for Health, The University of Edinburgh @narrowboat_paul 

References:

• Hanson, CL, Oliver, EJ, Dodd-Reynolds, CJ & Kelly, P (2019). We are failing to improve the evidence base for “Exercise Referral” How a Physical Activity Referral Scheme Taxonomy can help. [CR14] British Journal of Sports Medicine Published Online First: 17 December 2019. doi: 10.1136/bjsports-2019-101485
• National Institute for Health and Care Excellence. Physical activity: exercise referral schemes. National Institute for Health and Care Excellence, 2014. https://www.nice.org.uk/guidance/ph54/resources/physical-activity-exercisereferral-schemes-pdf-1996418406085 (Accessed 06 Jan 2020).
• Oliver EJ, Hanson CL, Lindsey IA, Dodd-Reynolds CJ. Exercise on referral: evidence and complexity at the nexus of public health and sport policy. International Journal of Sport Policy and Politics 2016;8:731–6.

Images: 

1. ‘Mr Motivator 2’ by Dave Tett via Flickr. Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0): https://www.flickr.com/photos/66551670@N00/388434590 © 2007.
2. 'Figure 1' reproduced from Hanson, CL, Oliver, EJ, Dodd-Reynolds, CJ & Kelly, P (2019). We are failing to improve the evidence base for “Exercise Referral” How a PhysicalActivity Referral Scheme Taxonomy can help. British Journal of Sports Medicine Published Online First: 17 December 2019. doi: 10.1136/bjsports-2019-101485 with permission from BMJ Publishing Group Ltd.