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Wednesday 26 October 2016
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Let's get physical

Let's get physical

GPs have always advocated patients’ fitness but often find their 10-minute appointment slots don’t allow for such a discussion. Since 2015 a programme has been in place across the UK that focuses solely on patient work-out sessions

Inactivity is a killer. That much we know. But persuading people to ditch long-term sedentary habits for regular exercise has long been the holy grail for many working in public health.
Prescribing statins, a group of medicines that can help lower the level of low-density lipoprotein (LDL) cholesterol in the blood, has in many cases become the easier option for those with heart disease. But with the NHS under increasing financial stress, this approach is not sustainable in the long run, and does nothing to address other escalating health issues caused by an inactive lifestyle, such as type 2 diabetes.
Exercise is cheap and it improves health overall. And now, thanks to the Let’s Get Moving (LGM) programme, run in partnership with ukactive, the not-for-profit health body for the UK activity sector, GP practices, and local authorities, demonstrable success in encouraging people to increase activity is emerging.
LGM focuses exclusively on people who are physically inactive and struggling with their health. Those taking part meet one-to-one with an exercise professional, trained in motivational interviewing, who, crucially, is based at their GP surgery, for up to 12 weeks.
They can be directed to community activities, peer-led group sessions, and offered one-to-one advice and support.

An active UK
During 2015 more than 1,800 patients attended LGM appointments, an increase of 60% on the previous year. So far it is offered in 29 surgeries across Birmingham, Luton, Bedfordshire, Essex and Kent, supporting thousands of patients to become more active.
Blueprint for an Active Britain, ukactive’s report (see Resources), published late last year and backed by a coalition of health experts including Mike Pringle, president of the Royal College of GPs and former health minister Lord Darzi, recommended that every GP surgery in the country should have access to a trained physical activity professional to help patients work on their cardio-respiratory fitness and improve their mental health.
The LGM scheme is a first step towards this goal, and previously unreleased data from ukactive shows that more than half of participants have recorded an improvement in their physical health.
Statistics tracking more than 600 patients in Luton and Bedfordshire show an increase in overall physical activity of 79%.
The data, based on the International Physical Activity Questionnaire, which was designed to provide a set of well-developed instruments that can be used internationally to obtain comparable estimates of physical activity, shows that those same patients walked 80% more after 12 weeks on the programme, took 60% extra vigorous exercise, and their level of moderate exercise rose by 48% during that time.
And the cost of this improvement is staggeringly low, the cost per additional quality adjusted life year (QALY) (the measure used by NICE to establish cost effectiveness of a treatment) for a physical activity intervention is between £20 and £440.
As a comparison, statins cost between £10,000 and £17,000 per QALY for patients aged 45 to 85, while smoking cessation interventions in the NHS cost between £221 and £9,515 per QALY.

LGM in practise
Debbie Wilkins is practice manager at the Kingsbury Court Surgery in Dunstable, Bedfordshire. Although a number of practices in her locality were interested in the programme, Wilkins was the only practice manager who felt confident her patient confidentiality systems and governance were able to cope with implementing LGM at the time.
The surgery provided information on all patients on its obesity register to the LGM team, who then wrote to patients informing them of the scheme and telling them that they would be contacted by telephone unless they chose to opt out. Very few patients refused the offer of a phone call.
“We didn’t have room to house the exercise professional at the surgery, but they were housed in a very nice site provided by Sustrans [a UK charity enabling people to travel by foot, bike or public transport] and the local council, who were trying to encourage people back on to buses. This tied in quite nicely as they had maps of walking routes and cycle paths,” says Ms Wilkins.
The exercise professional ran sessions all day on Thursdays and Saturday mornings for people in full-time work. He would visit the practice around once a month to share case studies with GPs and the practice manager. Ms Wilkins then shared these experiences with her local practice managers group and this persuaded at least one other practice to sign up to the scheme.
“One patient on our patient participation group did it [LGM] and he thought it was wonderful,” Ms Wilkins says.
“What he liked about it was that he thought the practice had picked him out and said that he could have this free service.”
She would recommend the LGM programme to other practice managers as long as they have strong patient confidentiality and information governance arrangements, and if they are prepared to deal with a small number of complaints if using a proactive approach to the scheme by contacting large number of patients, rather than waiting for referrals from GPs.
Dr Manpinder Sahota is a GP in Gravesend, Kent. His surgery – Pelham Medical Practice – has recently started referring patients to the LGM programme.
A GP for 17 years, Dr Sahota has seen an increasing number of patients with long-term health problems caused by poor diet and lack of physical activity. With high levels of deprivation, childhood obesity and chronic conditions, Dr Sahota says Gravesend was an ideal test-bed for a physical activity intervention.
“Patients do seem to respond and engage with an activity programme if it’s delivered in a GP surgery setting as it’s almost like they’ve been given a prescription, so they’re more likely to do it,” he says.
“People have strong attachments to their GP practice and trust that GPs want the best for them, so it enables us to be more effective. Personal trainers can spend the time talking to patients about how to get moving and doing more activity – the work that GPs would love to do but just don’t have the time,” he adds.
Dr Sahota believes the next step for LGM and similar interventions is to work with patients before their inactivity leads to the long-term conditions that are so debilitating for the patient, and expensive for the NHS.
“My long-term vision is to develop a health and wellbeing centre so I would have programmes like LGM in there permanently on a daily basis, with a gym and facilities which mean that I, as a GP, could refer patients to in-house services.”
Personal trainer Paul Coombes, who has worked with around 190 patients through the Let’s Get Moving programme at Kingsbury Court Surgery in Dunstable, Bedfordshire, says a lot of his focus goes into building confidence.
While many of the patients referred to him were overweight, they also included patients who had suffered strokes, and those with long-term conditions like diabetes and lung disease.
Paul coached his patients through the 12-week motivational interviewing programme, helped them set personal exercise goals, and signposted them to local physical activity sessions. He says his clients felt supported to make lifestyle changes.
“Some patients joined local walking groups, others joined gyms or zumba classes, and one man got so into it he ended up being a group leader,” Paul says.
One patient who was at risk of having a second stroke told Paul the programme had helped motivate her to visit the gym three times a week, which could prove to be a lifesaver.
The LGM model may be spreading to other spheres, and since its introduction, the template has been adapted and expanded to include some specialist groups.
In Bedfordshire, ukactive has worked with the National Childbirth Trust (NCT) to offer 12 weeks of specialised postnatal support to new mums from a community exercise professional.

Going further afield
LGM’s success has caught the eye of the government, and now the Cabinet Office, and social innovation charity Nesta has backed an expansion of the scheme to the voluntary sector, in the shape of a grant of almost £100,000.
The funding will help train volunteers as programme ambassadors and support community exercise professionals to run group activities. The money will also help create local peer support networks to strengthen and sustain the programme.
Dan Jones, director in Nesta’s innovation lab, says: “There was already strong evidence that when delivered by professional exercise coaches, the Let’s Get Moving project had a significant impact on levels of physical activity, and thus on health and wellbeing.
“The Centre for Social Action Innovation Fund, a £14million fund from the Cabinet Office and Nesta to support volunteers working alongside public services, was excited by the opportunity to build peer-to-peer support into this proven model, through volunteer-led exercise groups and online peer support.
“We were particularly interested in how this kind of voluntary support could help sustain increased exercise levels over the longer term.”

Mary-Louise Clews, freelance journalist and consultant.

Blueprint for an Active Britain –