Table 1 Chronology of key research, policy and practice events concerning exercise referral schemes (ERSs) in England
DateResearch on effectivenessGovernment policyExpansion of exercise referral schemes
199272 leisure centre-managed schemes identified20
1994Editorial21 “Any future prescription for exercise programmes should be carefully evaluated; the results will help in the design of a definitive multi-centre trial. Unevaluated initiatives may be of no more value than prescribing coloured water. While we await the results of careful evaluation, primary health care teams should look closely before they leap into prescribing exercise. There may be many far more effective ways for them to use their resources to increase the fitness of their practice populations” (p 495).52 more leisure centre-managed schemes planned for 199420
1996Systematic review22 of physical activity promotion strategies. Included 11 trials, none of which was undertaken in the UK. Small number of trials limited strength of conclusions. Called for more research.Over 200 primary care-based physical activity promotion schemes running6
1997Cross-sectional survey23 of physical activity promotion in primary care in England:
“The design of evaluation packages was unsophisticated. With the exception of one example, these evaluations did not involve randomisation or control groups….It became clear that schemes are inadequately resourced to conduct long-term rigorous evaluation” (p 368).
“Randomised controlled trials accompanied by process-oriented research methods are needed for the comparison of the long-term effectiveness of different types of physical activity intervention in primary health care, and their effectiveness for different patient groups” (p 369).
1998First UK randomised controlled trial (RCT) of exercise referral published24
Health Education Authority review6 “In contrast to the large number of UK schemes, evidence relating to effectiveness is sparse, and this is a matter of some concern at a time of scarce primary care resources and within a climate of evidence-based medicine” (p 12).
2000DH press release on ERSs25: “The Government is keen to extend the number of schemes in operation. We want to encourage more GPs and health professionals to encourage patients to be active and will be publishing new guidelines to encourage GPs, local authorities and health authorities to set up schemes and ensure that they are effective.”
2001DH National Quality Assurance Framework for Exercise Referral26
Aimed to raise standards and improve quality of local schemes.
2005Health Development Agency review8 “In the UK ‘exercise referral schemes’ are increasingly common yet remain under-evaluated. Much time, effort and resources are being invested in such programmes and therefore it is imperative that their effectiveness is evaluated through rigorous studies” (p 22).DH White Paper Choosing Health5Announced the production of specific guidelines for children’s exercise referral (p 142).Specified exercise referral as one of the treatment programmes for obesity (p 143).Announced the development of a patient activity questionnaire to assess patients’ need for interventions such as exercise referral (p 145).89% of primary care organisations in England run an exercise referral programme28Review of Greater London found that 97% of areas have an ERS29
Critique4 “This endorsement by government (the NQAF) has probably been a major factor in the rapid increase in the number of ERSs currently being implemented across the UK. It is of further concern that this proliferation has not been underpinned by a solid evidence base for their effectiveness” (p 1395).DH Action Plan Choosing Activity: A Physical Activity Action Plan27“Many primary care professionals are already involved in schemes to refer patients to facilities such as leisure centres or gyms for supervised exercise programmes. In 2001, the Department of Health (DH) published a National Quality Assurance Framework to improve the quality of existing referral schemes and help the development of new ones” (p 6).
Jan 2006NICE rapid review of effectiveness30DH White Paper Our Health, Our Care, Our Say31“A range of different ‘prescription’ schemes, such as exercise-on-prescription projects, have been established or piloted in a number of areas and have often been very successful. We would like to see increasing uptake of well-being prescriptions by PCTs and their local partners, aimed at promoting good health and independence and ensuring people have easy access to a wide range of services, facilities and activities” (p 51).
Concluded that exercise referral schemes had positive effects on physical activity levels in the short term (6–12 weeks), but were ineffective at increasing physical activity over a longer period (12 weeks).“There is insufficient evidence in any of the four RCTs examined to make any conclusions or recommendations about the effects of exercise referral on health inequalities” (p 4).
Mar 2006NICE guidance9
“PHIAC (Public Health Interventions Advisory Committee) determined that there was insufficient evidence to recommend the use of exercise referral schemes to promote physical activity, other than as part of research studies where their effectiveness can be evaluated. Recommendation Five: Practitioners, policy makers and commissioners should only endorse exercise referral schemes to promote physical activity that are part of a properly designed and controlled research study to determine effectiveness” (p 6).
May 2006NICE guidance implementation advice32
“Before withdrawing funding, it is important to consider the implications for the work of other partners, so that good partnership arrangements are not damaged for the future” (p 9).
NICE guidance costing report33
“A small sample of PCTs provided cost details and it was found that the average investment per scheme is £100,000 This is potentially a significant investment for something that has a thin evidence base….
…A further factor is the multi-sector and joint working arrangements that are in place. PCTs that withdraw support for joint schemes with local authority partners could expose the local authority to financial problems. It should also be noted that exercise schemes may be set up for other reasons than to increase physical activity, such as cardiac rehabilitation” (p 16).
Dec 2006LEAP evaluation summary report Dec 2006,34 full report April 200735DH press release announcing package of measures to combat physical inactivity36
Included five exercise referral schemes.“The sample of completers represented as little as 10% of the overall participant numbers…therefore there is potential self selection bias” (p 4).“Small sample sizes…not all participants provided data on demographic profile…there was no attempt to control for any covariates” (p 5).“Some sites experienced difficulties in developing the evaluation inside the required time frame” (p 115).“Data was not collected systematically where physical activity leaders were not motivated, or did not see data collection as ‘their job’” (p 119).“Data (were) collected…by those delivering the interventions that have a vested interest in the success of the intervention” (p 120).“The (LEAP) pilots demonstrated that physical activity interventions are cost-effective and can save the NHS money in the long term by reducing ill-health. LEAP has also shown that it is possible to engage a broad range of people, and to increase physical activity levels. Data collected found: Exercise referral schemes: Resulted in almost 70 per cent of those who were sedentary or lightly active to achieve or exceed recommended levels of physical activity. This was effective for adults and older adults.” (p 1).The 70% quoted is based on a sample of 460 people who participated in exercise referral pilots and provided both baseline and post-intervention physical activity measurements (see Department of Health,35 p 51).
March 2007HTA exercise evaluation single centre RCT (EXERT)10DH Best Practice Guidance37
Comparison of the effectiveness and cost-effectiveness of two structured exercise referral programmes (a leisure centre-based exercise programme and an instructor-led walking programme) with an advice-only group. Exercise referral programme was not more effective than advice only. Advice only was the most cost-effective intervention.“The Department of Health urges commissioners, practitioners and policy makers to continue to provide high quality exercise referral schemes for their local population where these address: (a) the medical management of conditions, e.g. type 2 diabetes, obesity and osteoporosis; (b) approaches specific to preventing or improving individual health conditions (e.g. falls preventions), which fall outside the overarching advice to achieve 30 minutes moderate activity on at least 5 days a week. Schemes should be commissioned and managed in accordance with the National Quality Assurance Framework for exercise referral in England. Exercise referral schemes solely for the purpose of promoting physical activity (i.e. where there is no underlying medical condition or risk) should only be commissioned or endorsed by commissioners, practitioners and policy makers when they are part of a properly designed and controlled research study to determine their effectiveness” (p 1–2).