Evidence
Alert

People in the most deprived groups were least likely to take part in the exercise referral scheme, study finds

Exercise referral schemes are designed for people with long term conditions that can be improved by exercise, such as raised blood pressure or mental health problems. They aim to encourage people to become more active, but evidence for the success of such schemes is mixed.

This study evaluated the Welsh National Exercise Referral Scheme and included almost 84,000 people. Although the scheme has been running since 2007, not much was known about how well it is working.

This is the first study to create linked electronic records of the people taking part in an exercise referral scheme. It found that people in the most deprived groups are least likely to be referred and least likely to take part in the scheme. Those referred for a mental health problem are also less likely to take part than those with physical conditions.

The data will be used to increase equality of access to this and other exercise referral schemes.

What’s the issue?

The National Exercise Referral Scheme (NERS) is one of more than 600 exercise referral schemes in the UK. It began in 2007 and runs across all Welsh local authorities.

To be referred, patients must be over 16 and classed as sedentary, meaning that they are active less than three times a week. They must also have, or be at risk of developing, a long-term condition that can be improved through exercise. Conditions include raised blood pressure, being overweight, family history of heart disease or diabetes, mild anxiety or depression, osteoporosis (weakened bones) or musculoskeletal pain.

People can be referred to an exercise programme by GPs, practice nurses, and physiotherapists. Following an initial consultation, these patients take part in 16 weeks of subsidised group activities such as aerobics, swimming, or exercising in a gym. After completing the programme, they are signposted to alternative exercise providers.

A study of NERS between 2007 and 2010 showed positive impacts on health and levels of physical activity. But there has been little further review since the scheme was scaled up across Wales. It is not known how many people take up the scheme after referral, what sectors of society are reached, how the scheme is being delivered, and what happens over the long-term. Knowing more would help maximise the impact of NERS and other exercise referral schemes.

What’s new?

This study included people who are sedentary and have one other health risk. All those referred between February 2008 and December 2017 - 83,598 people in all - were eligible for inclusion.

NERS gathers data about each patient from referral through to a 12-month post-scheme follow-up. Researchers linked this data to patients’ health records. They gave each patient a social deprivation score based on where they lived. All data were anonymised.

The study found:

  • one in thirty (3.3%) at-risk, sedentary patients were referred to NERS over the 10-year period
  • over half (58%) were referred to the scheme by their GP
  • around half (50.5%) were referred because they had a musculoskeletal condition
  • two in three patients (67.31%) took up NERS after referral which is a lower acceptance rate than in the initial trial
  • uptake peaked in 2010 when the scheme went live in all local authorities
  • referrals decreased over time, with referral and uptake rates among the most deprived groups falling most steeply
  • those least likely to take up NERS were men, people with mental health conditions, those from the most deprived areas, and those who were referred by health professionals other than GPs.

Why is this important?

High levels of inactivity combined with an ageing population mean that the demand for NERS is set to increase.

It is important that future services are accessible and fairly distributed. Historically, an objective of exercise referral schemes has been to improve health inequalities. Most chronic conditions are most common in deprived areas, so the need for exercise will also be greatest in these areas.

However, these findings suggest growing inequality in referral and uptake. Patients in the most deprived groups were the least likely to be referred and the least likely to take up the scheme. Pricing may be a factor. In 2011, an increase in the cost/session from £1.00 to £1.50 was followed by a rapid falling off of attendance among people in the most deprived groups.

Also of concern is the finding that only a small proportion of referrals were for mental health. Researchers need to understand why, and work out how to improve referral and uptake from people in these groups.

What’s next?

The NERS electronic records provide a secure and robust dataset. The people in this study are being followed to find out if there are unseen, longer-term benefits of NERS on physical and mental health, along with any impact on health service usage.

In an extension of the research, the team interviewed patients, health professionals, and deliverers of the NERS scheme. These interviews have helped uncover some of the reasons for the fall in referral and uptake rates. These data are building the researchers’ understanding of the scheme’s delivery and its future needs. The findings will be available soon.

The current research only included patients who were sedentary and had one other health risk. Since the inception of NERS, many other referral pathways have been created. These include a cardiac pathway, a pregnancy pathway, and a falls pathway. It would be useful to replicate the research on other patients to examine the reach, delivery, and impact of these alternative pathways.

You may be interested to read

The full paper: Morgan K, and others. Patterning in Patient Referral to and Uptake of a National Exercise Referral Scheme (NERS) in Wales from 2008 to 2017: A Data Linkage Study. Int J Environ Res Public Health. 2020;17:3942

The project website: Long-term Implementation and Effects of the National Exercise Referral Scheme (NERS) in Wales

 

Funding: This work was funded by Health and Care Research Wales and supported by the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research Centre of Excellence.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

We found that rates of uptake of the exercise scheme have been stable over the past five years. This is encouraging and shows the continued demand ten years on from scheme inception. But the pattern of scheme referral and uptake indicates growing inequality.

I’d like to see our research used to promote awareness of the equity of NERS among health professionals who can refer patients. It could help deliverers of the scheme to identify the best ways of reaching different groups of people. I hope our work will inspire exercise referral schemes worldwide to explore the possibilities for data linkage and longitudinal analyses of patient outcomes.

Kelly Morgan, Research Fellow, School of Social Sciences, Cardiff University

Lived experience

I am a service user who is clinically obese. My GP has prescribed exercise for me, but my chronic health problems make it challenging.

Referral to NERS is only the beginning. You then have to take up the offer. Starting the scheme was not too problematic for me. The main challenge was keeping going. Fitting exercise into a busy life can be exhausting. It competes with my work, caring responsibilities, leisure, social life, and voluntary work.

Ongoing support from the GP practice is pivotal in maintaining exercise regimes. There needs to be effective communication between the various primary care professionals. As well as the GP, dieticians and counsellors are well placed to identify the people likely to benefit.

Margaret Ogden, Public contributor

Health lecturer

It seems that people more in need of this intervention are less likely to take part. One factor identified in this research was the cost of sessions. This is likely to be a continuing aspect for the most deprived socio-economic groups.

It would be helpful to find ways of subsidising sessions for people in more deprived areas. I have seen an increase in physical activity marketed towards people with poor mental health. The low take-up amongst people with depression and anxiety needs further examination to find ways of enabling them to participate.

There may be room for more partnership work. For example, a GP practice could link up with a free, local parkrun.

Annette Helliwell, Senior Lecturer in Public Health, Anglia Ruskin University, London