East Midlands Clinical Senate Report Physical activity and exercise medicine

Transcription

1 East Midlands Clinical Senate Report Physical activity and exercise medicine

2 Report by Professor Mark E Batt Consultant Sport & Exercise Medicine East Midlands Clinical Senate Council member Suzanne Horobin East Midlands Strategic Clinical Networks and Senate

3 Content 1 Executive summary Definitions Background Facts East Midlands Research institutions Physical activity in the treatment of chronic disease The case for change in the East Midlands East Midlands physical activity needs Maintaining good health Risk reduction, rehabilitation and treatment RCP Commissioning Guidance Recommendations The Clinical Senate is supportive of the following initiatives Existing NICE guidelines Return on investment tools Public Health England - Everybody active, every day Third sector provision The Clinical Senate recommends the following be developed Lie less, sit less. Do more, more often (primary, secondary and tertiary prevention) Support the development of a network for existing East Midlands groups (enhanced secondary and tertiary prevention) Making every contact count: (primary, secondary and tertiary prevention) Signposting / messaging: physical activity on referral / sport & exercise medicine Training curricula Evidence the benefits / return on investment Physical activity as a treatment for mental health Thinking differently

4 Content 5.3 The Clinical Senate recommends the following be actively commissioned - across health and social care Education programme: Everybody active, every day: (primary, secondary and tertiary prevention) Healthy workplace Review of existing service provision Exercise medicine: (enhanced secondary and tertiary prevention) Appendices Chief Medical Officer Physical Activity Guideline Who is currently responsible for what? Examples of existing provision Leicestershire and Rutland Northamptonshire Derbyshire Nottinghamshire Referenced evidence base Literature review Collation and summary of existing professional and national guidelines Acknowledgements

5 1 Executive summary This report by the East Midlands Clinical Senate provides background information, a case for change and recommendations to encourage more people to be more active more of the time. The focus of the report is physical activity and the benefits to be obtained through its use in prevention of ill health, in risk reduction and as an active treatment. The Council recommends the support of a number of existing national initiatives, the development of regional programmes and networks and specifically the commissioning of: Education programme for healthcare professionals Healthy workplace interventions Review of existing service provision Exercise medicine services Clinical commissioners are encouraged to work in collaboration with Public Health colleagues to address the gaps in the current system. It is suggested that this report be read in conjunction with Public Health England s Everybody active, every day. Specifically, this report provides a framework for an East Midlands response. 5

6 2 Definitions Physical Activity: body movement that expends energy and raises the heart rate. Inactivity: less than 30 minutes physical activity a week. Sedentary: time spent in low-energy postures, eg, sitting or lying. Sport and exercise medicine (SEM): is a new speciality of medicine involving the medical care of injury and illness in sport and exercise. In primary care, SEM physicians can: Work with primary care teams and public health to support effective physical activity prescription, including providing education for the primary care team so that consistent, evidence based and effective physical activity interventions are provided. Provide expertise for patients requiring specialist input; for example those identified as high risk due to medical conditions and co-morbidity and those requiring more intense behavioural interventions. Provide locally based musculoskeletal services, bringing a range of additional skills such as leadership, triage, rapid access to ultrasound scans, evidence based injection therapies, specialised back pain services and chronic pain services etc. 6

7 2 Definitions In secondary care, SEM physicians can: Restructure and modernise existing rehabilitation services so they are patient-centred, evidence-based and inclusive of all chronic disease areas effectively treated by exercise. Establish multidisciplinary teams to provide a single point of referral for patients requiring specialist help to overcome their medical, social or cultural barriers to exercise. Establish SEM led clinics to work alongside existing orthopaedic, physiotherapy and emergency department services in identifying, treating and rehabilitating acute and chronic musculoskeletal disorders which do not require surgery. SEM physicians can support commissioners in specifying services for people who are unwell including pathways for personalising exercise interventions amongst those who do not feel they are able to exercise (anxious, overweight, musculoskeletal pain etc.) 7

8 3 Background This report should be read in conjunction with the Public Health England publication Everybody active, every day - An evidence-based approach to physical activity. Physical inactivity poses a serious and growing threat to our society - it is a pan-societal issue damaging our health, economy and environment. Levels of physical activity are declining and we need to act. Other high-income countries like Finland, the Netherlands and Germany have shown that the situation can be changed. The All Party Commission on Physical Activity report Tackling Physical Inactivity - A Coordinated Approach (2014) offered five recommendations: 1. A national action plan 2. Getting the message out 3. Designing physical activity back into our everyday lives 4. Making physical activity a lifelong habit 5. Proving success These recommendations have been followed by the Everybody active, every day report which provides the background and impetus for this report. 8

9 3 Background 3.1 Facts The Public Health report Everybody active, every day provides the following graphical summary of the current levels of physical inactivity. 18% of disabled adults regularly take part in sport compared to 39% of non-disabled adults 33% of men are not active enough for good health 45% of women are not active enough for good health 19% of men and 26% of women are 'physically inactive' 21% of boys and 16% of girls aged 5-15 achieve recommended levels of physical activity 23% of girls aged 5-7 meet the recommended levels of daily physical activity, by ages only 8% do 47% of boys and 49% of girls in the lowest economic group are 'inactive' compared to 26% and 35% in the highest Walking trips decreased by 30% between 1995 and % of trips are made by car 22% are made on foot 2% are made by bike Data sources: Health Survey for England 2012 (HSE); Active People Survey 8, April 2013-April 2014 (APS); National Travel Survey 2013 (NTS) 9

10 3 Background 70% of NHS spend is on long-term conditions. As long ago as 2002 the Wanless report Securing our future health (2002) (and later - Securing health for the whole population (2004)) confirmed that with no increased investment in chronic disease prevention our healthcare economy is not sustainable in the long-term. On average, an inactive person spends 38% more days in hospital than an active person, and utilises 5.5% more GP visits, 13% more specialist services and 12% more nurse visits than an active individual. The UK faces an epidemic of physical inactivity - we have dramatically engineered movement out of our lives, to the extent that humans have never been so inactive. Only 39% of men and 29% of women in the UK meet minimum physical activity recommendations when measured subjectively and 5% when measured objectively. The population does not understand the consequences of physical inactivity - low fitness kills more people than smoking, diabetes and hypertension combined. Healthy life expectancy is increased by physical activity Only one third of the population take enough physical activity to maintain good health. There exists a significant gap in perception and reality regarding how active we are. Physical inactivity contributes to 1:10 premature deaths (37,000 in England annually): a greater cause of death in the UK compared to USA (more obesity), France and The Netherlands. Diet and physical inactivity accounted for 14.3% (95% UI ) of UK disability adjusted life years in

11 3 Background The effects of physical activity are largely independent of obesity or weight loss. In other words, the benefits of physical activity are achieved even in the absence of weight loss; hence the advice that it is better to be fat and fit than lean and unfit. If the practical problems of changing the behaviour of the population could be addressed, the benefits to the NHS could be very significant: - 30% to 50% reductions of risk in the development of common chronic conditions, including cancer, ischaemic heart disease, obesity and diabetes, dementia and depression. - Significant improvements in the efficacy of treatment of those same chronic conditions - Improved outcomes, patient satisfaction and reduced costs (many fewer GP and orthopaedic presentations) for musculoskeletal injuries. A Macmillan Cancer Support publication Move More states that there are two million cancer survivors in the UK and estimates that 1.6 million are not physically active to recommended levels In order for the population of the East Midlands to maintain good health 20 million hours of physical activity per week are required. Sedentary behaviour is emerging as an important target in the prevention and treatment of chronic disease. Although often used interchangeably, sedentary behaviour and inactivity are different constructs and need different solutions. 11

12 3 Background Sedentary time refers to all non-exercise sitting time and inactivity refers to those who fail to meet the physical activity guidelines. Hence it is possible to be active, but still have high sedentary behaviour. A journal article for Diabetes Research and Clinical Practice (2011) Stand up for your health: Is it time to rethink the physical activity paradigm? confirms that although the importance of physical activity in the prevention and treatment of chronic disease is clear and must remain, there is increasing evidence that it will not offset the deleterious effects associated with sedentary behaviour. Strategies based on simply sitting less and standing more are therefore expected to revolutionise the health promotion field in coming years. 3.2 East Midlands Research institutions The East Midlands could be heralded as the national exemplar for attracting funding in the area of physical activity, sedentary behaviour and health, particularly from the National Institute for Health Research (NIHR). We have in our region a resource with which to translate and commission evidence-based physical activity-based interventions and programmes. The government has invested substantial resources into developing and evaluating physical activity-based therapies locally. This report poses the question - why aren t these services more commonly commissioned? 12

13 3 Background Some of the research infrastructure is listed below: NIHR Leicester-Loughborough Diet, Lifestyle and Physical Activity Biomedical Research Unit - Focused on using experimental research to extend the range of evidence-based physical activity-based therapies - The only BRU funded nationally that has a specific focus on physical activity million in funding over five years - DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed): Walking away from diabetes walkingaway-280.html NIHR East Midlands Collaboration for Leadership in Applied Health Research and Care (EM-CLAHRC) - Focused on translating evidence-based medicine into routine care - Strong focus on lifestyle, including physical activity - 10 million in direct funding and 10 million in matched funding over five years - Specific interventions to empower individuals focusing on chronic obstructive pulmonary disease (COPD) self-management strategies and post-cardiac rehabilitation options - The use of technology to support selfmanagement in people with chronic disease. 13

14 3 Background National Centre for Sport and Exercise Medicine in the East Midlands (NCSEM-EM) - Part of the Olympic legacy in conjunction with sites in London and Sheffield - Remit for extending the SEM profession into the prevention and treatment of chronic disease - 10 million for a state of the art facility on Loughborough University campus: opens Leicester Diabetes Centre - One of the largest diabetes research centres in Europe - Strong track record in developing and evaluating lifestyle intervention in the prevention and management of type 2 diabetes and other chronic diseases - Includes a specialist group of physical activity and sedentary behaviour researchers - Developed the Leicester Prevention Pathway that includes a range of fully evaluated resources for: 1) identifying those within primary care that have a high risk of type 2 diabetes, 2) confirming risk status (blood test), 3) information leaflet including physical activity, and 4) referral onto a suite of prevention programmes that are based on the promotion of increased physical activity and other lifestyle behaviours, including the Walking Away from Type 2 Diabetes Programme. Parts of the pathway, including Walking Away, have been widely commissioned nationally. However local provision has been patchy and sporadic. 14

15 3 Background 3.3 Physical activity in the treatment of chronic disease The Faculty of Sport and Exercise Medicine in the UK s recent report A Fresh Approach in Practice (2013) states that increasing activity levels can inexpensively treat chronic disease, musculoskeletal conditions and sports injuries. This is in addition to the decrease in chronic disease risk by 30-50%, prevention of co-morbidity and aiding recovery, function and improving quality of life in those who do suffer from chronic disease. The report shares a number of examples of services which have delivered a return on investment. A community musculoskeletal service in Newcastle West reduced secondary care orthopaedic referrals by 40%, improved the efficiency of the orthopaedic outpatient conversion to surgery to 82%, and lowered rheumatology referrals by 8% and neurosurgery by 44%. It also delivered a reduction in cost of 42k. There exists a commonality of risk factors for chronic diseases (1:2 cancer diagnoses have 2+ other chronic diseases), thus treating these conditions in isolation is nonsensical. It is envisaged that savings may be found using physical activity to treat chronic diseases. (Table 1) 15

16 3 Background Chronic disease Effect of exercise therapy Ischaemic heart disease COPD Breast cancer Bowel cancer Cerebrovascular disease Diabetes Impaired glucose tolerance Hypertension Depression/anxiety disorders Rheumatoid arthritis Osteoarthritis Osteoporosis Pregnancy 35-40% reduction in risk of event Improvement in aerobic fitness, quality of life, symptoms of dyspnoea, CV risk factors 50% reduction RR of breast cancer death 50% reduction in bowel cancer death Improvement of tolerance of cancer treatment Improvement of aerobic capacity, sensorimotor function and CV risk factors 42% reduction in diabetes related mortality 32% reduction in diabetes related complications 42% reduction in risk of developing diabetes Reduce systolic BP by 7.4mmHg and diastolic BP by 5.8mmHg Effect as good as standard pharmacological treatments for moderate depression Improved aerobic fitness, disease activity, function and QoL Improved aerobic capacity, reduce fatigue and pain. Improve muscle strength and function Reduction in risk of falls. Maintenance of BMD in men and postmenopausal women Reduce risk of pregnancy induced diabetes Table 1 - The effect of physical activity on chronic diseases - Faculty for Sport and Exercise Medicine Long term physical activity adherence for those with chronic disease remains low. Compliance can be improved by specific behavioural interventions, focusing on self-efficacy and sensitivity to the complex and individual social, medical and cultural barriers which preclude people with chronic disease from long term physical activity. In their report Everybody active, every day, Public Health England outline four domains for action to create the required cultural change that will achieve the simple outcome of everyone being more active. 16

17 4 The case for change in the East Midlands The evidence for physical activity in the prevention and treatment of chronic disease has been building over the past few years, and is encapsulated by the Public Health England report Everybody active, every day. This report from the East Midlands Clinical Senate Council is a call to action for commissioners in the East Midlands to contribute to the overall effort to affect the required change in our region. 4.1 East Midlands physical activity needs The UK Active report Turning the tide of inactivity confirms that: The East Midlands has one of the lowest proportional public health spends on physical inactivity (1.8%) compared to the national average (2.4%) Large urban areas, such as Leicester and Nottingham, have higher than average levels of adult physical inactivity (33-34%) Physical inactivity is lower in less densely populated, affluent areas such as Rutland (24%) The region has a higher than average proportion of green spaces (the proportion of region made up of green and open spaces) (60%) compared to the national average (46%) 17

18 4 The case for change in the East Midlands Maintaining good health Physical activity guidelines for the maintenance of good health were set out by the four Home Countries Chief Medical Officers (CMO) in the 2011 report Start Active, Stay Active. These guidelines built on the previous advice through the addition of age specific guidance, and activity type recommendations. (Appendix 6.1) It is acknowledged that some groups need relatively more physical activity to gain benefits for health. Table 2 below outlines the recommendations and identifies the total physical activity needed for the maintenance of good health across the East Midlands population - a total of 19.3 million hours of physical activity per week. Age East Recommended Recommended activity type Total weekly group Midlands daily activity physical population activity requirement 0-4s 297, minutes Light activity such as standing 4.39 million total active once up, moving around, rolling hours (209,157 walking (proxy and playing, as well as more between 18 from 18 energetic activity like skipping, months and months) hopping, running and jumping. 5 years) Active play, such as using a climbing frame, riding a bike, playing in water, chasing games and ball games, is the best way for this age group to be physically active. 18

19 4 The case for change in the East Midlands Age group East Midlands population Recommended daily activity 5-18s 788,122 Moderate to vigorous activity for 60 minutes up to several hours per day Recommended activity type Vigorous intensity including bone and muscle strengthening on at least 3 days / week. Examples of energetic activities suitable for most children who can walk on their own include: active play (such as hide and seek and stuck in the mud) fast walking riding a bike dancing swimming climbing skipping rope gymnastics Energetic activity for children will make kids huff and puff and can include organised activities, like dance and gymnastics. Any sort of active play will usually include bursts of energetic activity. Total weekly physical activity requirement 5.52 million hours 19-64s 2,901,665 At least 150 minutes per week moderate intensity (or 75 minutes vigorous) per week Bone and muscle strengthening on at least 2 days / week million hours 19

20 4 The case for change in the East Midlands Age group East Midlands population Recommended daily activity ,159 At least 150 minutes per week moderate intensity (or 75 minutes vigorous) per week TOTAL Recommended activity type Bone and muscle strengthening on at least 2 days /week, plus balance exercise for those at risk of falls. Total weekly physical activity requirement 2.17 million hours 19.3 million hours per week Table 2: Physical activity requirements for the maintenance of good health for the East Midlands Examples of activities that require moderate effort for most people include: walking fast water aerobics riding a bike on level ground or with few hills ballroom and line dancing doubles tennis pushing a lawn mower hiking skateboarding canoeing rollerblading volleyball basketball 20

21 4 The case for change in the East Midlands Moderate-intensity activity raises the heart rate and results in breathing faster and feeling warmer. One way to tell if activity is at the level of moderate intensity is if it is possible to still talk but not sing the words to a song. Examples of activities that require vigorous effort for most people include: jogging or running aerobics swimming fast riding a bike fast or on hills playing singles tennis playing football hiking uphill energetic dancing martial arts Vigorous-intensity aerobic activity means you re breathing hard and fast, and your heart rate has gone up quite a bit. If you re working at this level, you won t be able to say more than a few words without pausing for a breath. Sport England data (Active People Survey ) shows that less than a third of adults aged 16 and over are achieving an average of 90 minutes of moderate intensity physical activity per week (12 x 30 minutes moderate intensity physical activity over the past 4 weeks) within the East Midlands, a level well below the 150 minute per week recommended for the maintenance of good health. 21

22 4 The case for change in the East Midlands Local Authority % Achieving 3 x 30 mins CCGs moderate activity per week Rutland 30.7% East Leicestershire & Rutland Milton Keynes 28.7% Milton Keynes Northamptonshire 27.61% Nene Corby Leicestershire County 27.6% West Leicestershire East Leicestershire & Rutland Nottinghamshire County 27.4% Mansfield & Ashfield Newark & Sherwood Nottinghamshire Erewash Rushcliffe Nottingham North and East Nottingham West Derbyshire County 25.7% South Derbyshire North Derbyshire Erewash Hardwick Lincolnshire County 25.0% South Lincolnshire South West Lincolnshire Lincolnshire East Lincolnshire West North Lincolnshire Nottingham City 24.6% Nottingham City Derby City 22.6% South Derbyshire Leicester City 19.7% Leicester City Table 3: The percentage of the adult (age 16 and over) population in a local area who participate in sport and active recreation, at moderate intensity, for at least 30 minutes on at least 12 days out of the last 4 weeks (equivalent to 30 minutes on 3 or more days a week). Sport England APS8. 22

23 4 The case for change in the East Midlands Risk reduction, rehabilitation and treatment It is important to note that the Chief Medical Officer recommendations focus on the physical activity requirements for the maintenance of good health. (Appendix 6.1) Physical activity can also be used to reduce risk of certain conditions, for rehabilitation following the effects of injury or acute health events (such as myocardial infaction or a severe chronic obstructive pulmonary disease related event) or as treatment to reduce or alleviate symptoms. In these instances there may be a need for more specific exercise prescription to ensure the achievement of clinical benefit, with the frequency, intensity, duration and type of exercise varying from and potentially exceeding the recommended levels for the maintenance of good health. Table 4 highlights the potential for health gain from physical activity, identifying the GP registered prevalence (QOF 2012/13 data) for those conditions which are amenable to prevention and/or treatment with physical activity and exercise. CASE STUDY An exercise referral outreach class takes place weekly in a Leicestershire village hall. Classes are run for GP referral patients and for cardiac / pulmonary rehabilitation referral patients. One of the patients attending is living with cancer. She is receiving palliative treatment. She has been attending the GP referral outreach class for around 10 months when she feels well enough and receives chemotherapy treatment every three weeks. She was told by her doctor that she needed to take up some form of exercise and was told that any exercise which would help to strengthen her bones would help her condition. The sessions provided are at the right level for her to participate and they help to manage her condition. Her consultant has confirmed that her condition is stable. The outreach class has helped this lady to take up some form of structured activity which has in turn helped her to undertake the necessary exercise in order to strengthen her bones as recommended by her doctor. 23

24 4 The case for change in the East Midlands Conditions amenable to prevention or treatment with physical activity/ QOF register prevalence for Midlands and East region Estimated number of affected individuals for the East Midlands exercise Asthma 6.2% 300,974 Atrial Fibrillation 1.6% 77,671 Cancer 2.0% 97,088 Coronary Heart Disease 3.4% 165,050 Chronic Kidney Disease (18+) 4.6% 176,146 Chronic Obstructive 1.7% 82,525 Pulmonary Disease Cardiovascular Disease 2.3% 111,652 Dementia 0.6% 29,127 Depression (18+) 6.0% 229,755 Diabetes (17+) 6.3% 244,976 Heart Failure 0.8% 38,835 Hypertension 14.3% 694,182 Hypothyroidism 3.4% 165,050 Obesity (16+) 11.2% 442,107 Osteoporosis (50+) 0.2% 3,555 Peripheral Artery Disease 0.6% 29,127 Stroke/TIA 1.7% 82,525 Table 4 - GP registered prevalence (QOF 2012/13 data) for those conditions which are amenable to prevention and/or treatment with physical activity and exercise A key issue is getting a population to be more physically active, either as a preventative measure (wellness) or as a part of the treatment of chronic disease or musculoskeletal injury. The challenge is to persuade the sedentary, unfit and unwell to change their behaviour. This behavioural change requires an investment of time and training to create the expertise to provide advice, encouragement and selective long term monitoring. 24

25 4 The case for change in the East Midlands Whilst this report does not seek to map current provision across the whole of the East Midlands we would like to highlight that there is inequity of provision. A report is expected from Health Education East Midlands working with the British Heart Foundation and Oxford University that will describe current exercise rehabilitation service provision across the country. Existing commissioned services are often disease-based. For example, exercise rehabilitation services for cardiac, pulmonary and renal diseases. A number of third sector and private providers also offer silo-based physical activity programmes, both commissioned and charitably funded. There is an opportunity for alignment of physical activity messaging and symptom based service delivery where it is clinically appropriate to do so. CASE STUDY Agnes Graham is known as Nessa. Nessa is visually impaired, which means that she has absolutely no vision at all. She joined a Leicestershire exercise referral scheme in March 2014 and has been attending the gym twice a week ever since then. Despite her impairment, Nessa walks with her guide dog which in itself takes determination and courage. Through sheer hard work, Nessa has managed to increase her fitness levels and lose over a stone in weight. Attending the gym has made a significant difference to Nessa s life and she has made new friends. Nessa is a total inspiration to everyone! She recently won an Exercise Referral and Healthy Heart Scheme award at the Leicestershire and Rutland awards evening. 25

26 4 The case for change in the East Midlands 4.2 RCP Commissioning Guidance The Royal College of Physicians (RCP) advises that sport and exercise medicine is not simply a specialty for the management of elite athletes medical conditions but is central to the promotion of physical activity as a means of disease prevention, to enhance well-being and in the management of disease. Spanning primary, secondary and tertiary care, the role of a sport and exercise consultant includes leading or supporting multidisciplinary teams using expertise in physiotherapy, nutrition, psychology, musculoskeletal and general medicine. The work may involve promoting physical activity in special groups such as pregnant women, those with diabetes, cardiovascular disease and the overweight and obese (both adults and children), as well as managing musculoskeletal injuries, and working with sports men and women on all aspects of performance, injury and illness minimisation. Working with colleagues in public health, the Department of Health and the NHS to implement policies that enhance health, sport and exercise medicine has a key role in developing new approaches to healthcare and promoting population health. 26

27 4 The case for change in the East Midlands RCP advice on key points to consider when commissioning sport and exercise medicine services: Global physical inactivity causes 9% of premature deaths, 5.3 million of the 57 million deaths that occurred in Maintaining physical activity at recommended levels can equate to three-four years in additional life expectancy with risk reductions of the order of 20-40% for over 22 non-communicable diseases. The NHS could make substantial savings by targeting promotion of physical activity as part of chronic disease models. Current costs of providing healthcare cover for a physically inactive ageing population are not sustainable. The NHS needs to invest proportionately to the burden of physical inactivity to develop sustainable prevention and treatment models for chronic disease. Sport and exercise medicine consultants are trained in providing evidence-based and effective physical activity interventions for primary and secondary prevention of chronic disease. Sport and exercise medicine consultants offer unique and specific skills in the diagnosis, treatment and rehabilitation of musculoskeletal, soft-tissue and sport injuries. Sport and exercise medicine services may be situated in both community and secondary care settings, and tailored to meet local pressures and needs. 27

28 5 Recommendations The East Midlands Clinical Senate is supportive of physical activity to enhance health and recognises the need for pansocietal solutions. The provision of physical activity in the prevention and treatment of ill-health is recognized as not wholly a healthcare responsibility. In addition to being supportive of a number of initiatives already underway, this report makes specific recommendations to commissioners relating to actions to improve the availability of physical activity as a preventative and a treatment measure. These recommendations are based on an understanding of the role of physical activity in primary, secondary and tertiary prevention strategies for chronic diseases linked to physical inactivity. 5.1 The Clinical Senate is supportive of the following initiatives Existing NICE guidelines PH Behaviour change: the principles for effective interventions PH Physical activity and the environment PH Promoting physical activity in the workplace PH Promoting physical activity for children and young people PH Walking and cycling: local measures to promote walking and cycling as forms of travel or recreation PH Obesity: working with local communities PH Physical activity: brief advice for adults in primary care PH Behaviour change: inidividual approaches PH Exercise referral schemes to promote physical activity 28

29 5 Recommendations Return on investment tools Public Health England has published a Guide to online tools for valuing physical activity, sport and obesity programmes which provides an overview of a number of resources including: Public Health England obesity economic impact tool World Health Organisation Health Economic Assessment Tool (HEAT) for walking and cycling Sport England Model for estimating the Outcomes and Values in the Economics of Sport (MOVES) NICE Physical activity return on investment tool Sport England Economic Impact of Sport - Local Model PHE/Sustrans Health Impact of Physical Inactivity (HIPI) tool Public Health England - Everybody active, every day Public Health England publishes their physical activity implementation framework in October Senate Council members have supported expert groups since August 2014 to consider the detail of how this will be rolled out. The Clinical Senate is supportive of the advice and would welcome an East Midlands wide physical activity programme. 29

30 5 Recommendations The Clinical Senate Council is supportive of a social movement for a more active society, creating a network of trained professionals, all working in an environment more conducive to physical activity Third sector provision There is an interest within the Richmond Group of charities (and others) in reviewing existing disease and conditionbased physical activity provision with a view to considering whether symptom-based provision - such as fatigue, weakness and breathlessness - would better meet patient need and be more cost effective. Alongside charities working to support health are organisations with a responsibility for green spaces. The Clinical Senate would be supportive of further discussions between these two sectors to consider working together to further enhance provision of services. 30

31 5 Recommendations 5.2 The Clinical Senate recommends the following be developed Lie less, sit less. Do more, more often (primary, secondary and tertiary prevention) An East Midlands wide physical activity awareness programme is needed to encourage individuals to take responsibility for appropriate levels of physical activity. Sticky messages that complement campaigns already in existence e.g. Change for Life (2009) and campaigns aimed at all are required. The NICE return on investment tool would suggest that targeted promotion of messages is more effective at local level - through schools, primary care lists and health check programmes Support the development of a network for existing East Midlands groups (enhanced secondary and tertiary prevention) In order to support commissioners and providers to maximise the beneficial outcomes from existing services, it is proposed that interested groups are brought together to form an East Midlands network. It is recognised that some services require specialist services (for example stroke). There are however opportunities for currently silo based services such as cardiac, pulmonary, renal and cancer to be reconfigured to provide symptom specific services to address, for example, fatigue, weakness and reduced aerobic capacity. 31

32 5 Recommendations There is significant evidence of the efficacy of networks in achieving change at scale in the current Strategic Clinical Network supported structures in areas such as cancer and cardiovascular disease Making every contact count: (primary, secondary and tertiary prevention) Across the healthcare community, at each patient / client encounter every health and social care professional should feel confident about asking lifestyle questions that include physical activity level. They should be suitably informed to be able to deliver physical activity advice where appropriate and signpost supportive services. The Making Every Contact Count website encourages conversations based on behaviour change methodologies (ranging from brief advice, to more advanced behaviour change techniques), empowering healthier lifestyle choices and exploring the wider social determinants that influence all of our health. Whilst it does not deal specifically with physical activity, it provides resources to assist individuals and organisations to deliver their approach. For example, the Making Every Contact Count self-assessment tool provides a way to identify and review existing skills in relation to Prevention and Lifestyle Behaviour Change: A Competence Framework and plan how to improve those skills. It helps answer the question am I making every contact count? 32

33 5 Recommendations Signposting / messaging: physical activity on referral / sport & exercise medicine It is recognised that the availability of activity on referral schemes, which are commissioning by public health (local authority), is not always well understood in healthcare services. Availability and signposting of services is patchy. There is an opportunity to make better use of available services and to better embed them into clinical pathways. There is a need to evaluate sustained change in physical activity levels and to understand return on investment for commissioners. In order to maximise the use of available activity on referral schemes and sport and exercise medicine expertise it is recommended that commissioners ensure local understanding of what is available, who should be referred and how to go about doing so. Suggested actions include: Stakeholder engagement, marketing and communication about activity on referral schemes with all healthcare professionals and provider organisations - not just in primary care. Ensuring available services are set up to receive referrals from across the spectrum of healthcare services/providers. Commission sport and exercise medicine services, specifically exercise medicine. Training to ensure understanding when to refer to a network of sport and exercise medicine specialists including patients with illness or injury preventing physical activity. 33

34 5 Recommendations Training curricula Education training and support should be implemented across the East Midlands to support these initiatives including but not limited to: Medical school curricula Nursing curricula Allied health professionals training curricula Junior doctor continuing professional development GP vocational training scheme There is a need to streamline and simplify existing advice and resources to enable healthcare staff to respond to patient need - what to advise patients to do and how to access support. Linked to this is an absolute requirement to upskill the healthcare community to employ motivational interviewing skills Evidence the benefits / return on investment Physical activity services delivering both prevention and treatment of ill health should be contracted and managed to ensure their value is evidenced. It is recommended that services are monitored and providers required to evidence performance across the dimensions of quality, cost, delivery, safety and morale. See examples on table 6 34

35 5 Recommendations QUALITATIVE Quality Cost Delivery Safety Morale Patient Patient Description of Patient feedback feedback adverse patient feedback events Complaints and compliments Individual Cost per Waiting lists Number of Percentage patient health patient adverse patient of patients results (eg. Percentage events continuing sedentariness Cost per of patients activity levels & associated session completing post six months adverse health programme QUANTITATIVE parameters - eg blood pressure, HBA1C) Fixed costs Variable costs Cost avoidance Percentage of patient referrals accepted Percentage (e.g. drugs of patients cost) continuing activity levels post six months Table 6 - Examples of measures 35

36 5 Recommendations Physical activity as a treatment for mental health Whilst there is a general lack of well designed and large trials using clinical populations of people with mental health problems, the largest trial with adults - the TREAD trial (funded by HTA an published in BMJ) questioned the value of exercise for depression. Subsequent review papers questioned the conclusions drawn. There remains a need for large scale, multi-centre trials in both adults and children and young people with mental health problems. It is accepted that engaging in exercise can have numerous positive benefits on mental wellbeing and psychological functioning both in children and young people. Specifically, it has been reported that engaging in exercise can lead to improvements in self-esteem and self-perception, mood, sleep and insomnia and psychological stress. Exercise can also lead to symptom improvement for people experiencing mental health problems. Studies have documented the effect of physical activity on various mental health disorders. Exercise as a preventative measure and a treatment for depression has been increasingly researched in adult populations over the previous three decades, with numerous studies reporting positive and encouraging results. It has been established that exercising, even at levels below those recommended by the Chief Medical Officer, can be sufficient to elicit reductions in depression. 36

37 5 Recommendations Thinking differently Commissioners are encouraged to consider alternative approaches to directing patients to physical activity services. Recognising the considerable pressure on GPs, it may be possible to engage pharmacists support. When a patient presents a prescription for hypertension for the first time - for example, could a pharmacist make a judgement on whether to swap their prescription for a green one? Pharmacies could continue to monitor patient s blood pressure and receive payment for the prescription as they would if providing drug therapy. It should not just be the responsibility of primary care to ask questions of patients about their levels of activity: the biggest cause of liver disease (cirrhosis) in the UK is obesity (greater than alcohol and viral hepatitis combined). Do patients who see a physician get asked about activity levels and do these professionals have access to referral schemes for their patients? 5.3 The Clinical Senate recommends the following be actively commissioned - across health and social care Education programme: Everybody active, every day: (primary, secondary and tertiary prevention) Education programmes for all healthcare professionals to enable provision of lifestyle advice to include physical activity both as a preventative and as management for long term conditions. 37

38 5 Recommendations Motivational interviewing is an essential skill for health and social care professionals to assist patients and clients to develop positive habits Healthy workplace All employers should consider how to create healthy workplaces for their own staff in addition to provision of the required education and support to ensure they feel confident to make every contact count. In the region there is an opportunity to link to the work of the East Midlands Platform on Food, Physical Activity and Health The Workplace Wellbeing Charter provides employers with an easy and clear guide on how to make workplaces a supporting and productive environment Within the NHS there should be a focus on augmenting and spreading areas of good practice in workplace wellness, with a focus in return to work. A good example is Nottingham University Hospitals Review of existing service provision Whilst it is recognised that there are examples of excellent services available within the East Midlands aimed at both prevention and treatment of ill health we do not have equitable provision across the region. Patients often experience more than one health challenge and their needs for support to access physical activity are likely to cut across existing silo based provision. Consideration should be given to co-morbidities and the development of symptom-based services (rather than condition specific). 38

39 5 Recommendations It is recommended that commissioners seek to understand the overall level of demand for both preventative and treatment based physical activity services in their healthcare community. Areas to consider might be who would benefit from physical activity - preventative and treatment focused? define patient groups - primary prevention - by disease area, prevalence and patient numbers - current GP attendance by exercisers with a problem preventing them from undertaking their usual activities - chronic medical problems that physical activity would help - by disease area and prevalence and patient numbers - annual musculoskeletal injury numbers - mental health A review of existing provision should follow that takes in all local provision - both directly commissioned services and those contained within block contracts and disease pathways to consider the benefits of re-commissioning services on a symptom basis. It is felt that bringing pockets of silo based activity together into larger services will enable removal of multiple administrative efforts and increase the percentage of time spent on patient facing delivery of services. Scope for greater innovation and partnership working with commercial partners should be considered. For example, providing physiotherapy services from a gym might encourage people who have never been in such an environment to increase their physical activity over and above participation in therapy. 39

40 5 Recommendations It is appreciated that some specialist services should remain so - for example stroke rehabilitation and post myocardial infarction cardiac rehabilitation Exercise medicine: (enhanced secondary and tertiary prevention) Commissioners are encouraged to support, develop, pilot and evaluate exercise medicine services for those: wishing to become more physically active but with medical and/or musculoskeletal issues preventing uptake needing physical activity for the treatment of chronic disease with rehabilitation needs, including return to work There is an additional role for specialist sport and exercise medicine services to provide support and leadership for the delivery of wider physical activity in both prevention and treatment. The National Centre for Sport & Exercise Medicine (NCESEM) can provide primary and intermediate care networking opportunities. Commissioned services should be embedded with local authority run physical activity and lifestyle programmes. The Faculty of Sport and Exercise Medicine offer the following advice: It is expected that different localities will choose to implement sport and exercise medicine services in variable ways and over differing timescales according to local needs. The development of sport and exercise medicine services can be flexible according to local pressures and needs. 40

41 6 Appendices 6.1 Chief Medical Officer Physical Activity Guideline For early years (under fives) 1. Physical activity should be encouraged from birth, particularly through floor-based play and water-based activities in safe environments. 2. Children of pre-school age who are capable of walking unaided should be physically active daily for at least 180 minutes, spread throughout the day 3. All under fives should minimize the amount of time spent being sedentary (being restrained or sitting) for extended periods (except time spent sleeping) These guidelines are relevant to all children under five, irrespective of gender, race or socio-economic status, but should be interpreted with consideration for physical and mental capabilities. For children and young people (five to 18 years) 1. All children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes and up to several hours every day. 2. Vigorous intensity activities, including those that strengthen muscle and bone, should be incorporated at least three days a week. 3. All children and young people should minimize the amount of time spent being sedentary (sitting) for extended periods. Based on evidence, the guidelines can be applied to disabled children and young people, emphasising that they need to be adjusted for each individual based on that person s exercise capacity and any special health issues or risks. 41

42 6 Appendices For adults: 1. Adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes of moderate intensity activity in bouts of ten minutes or more - one way to approach this is to do 30 minutes on at least five days a week. 2. Alternatively, comparable benefits can be achieved through 75 minutes vigorous intensity activity spread across a week or a combination of moderate and vigorous intensity activity 3. Adults should also undertake physical activity to improve muscle strength on at least two days a week 4. All adults should minimize the amount of time spent being sedentary (sitting) for extended periods. Based on the evidence, the guidelines can be applied to disabled adults, emphasising that they need to be adjusted for each individual, based on that person s exercise capacity and any special health risks or risk issues. For older adults (65 plus years) 1. Older adults who participate in any amount of physical activity gain some health benefits, including maintenance of good physical and cognitive function. Some physical activity is better than none, and more physical activity provides greater health benefits. 2. Older adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes of moderate intensity activity in bouts of ten minutes or more - one way to approach this is to do 30 minutes on at least five days a week. 3. For those who are already regularly active at moderate intensity, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or a combination of moderate and vigorous activity. 42

43 6 Appendices 4. Older adults should also undertake physical activity to improve muscle strength on at least two days a week. 5. Older adults at risk of falls should incorporate physical activity to improve balance and coordination on at least two days a week. 6. All older adults should minimize the amount of time spent being sedentary (sitting) for extended periods. Based on the evidence, the guidelines can be applied to disabled older adults emphasising that they need to be adjusted for each individual based on that person s exercise capacity and any special health or risk issues. 6.2 Who is currently responsible for what? Physical activity is not mandated in public health outcomes but health checks are There are no ring fenced budgets for physical activity o Children s services Physical literacy is part of the health visitor offer and early years foundation stage curriculum Physical education curriculum in schools School nurse role in picking up child obesity, promoting positive health and making referral/ recommendation where risk identified Sport England - activity targets including active travel along with sports governing bodies sport participation targets Local authorities promote physical activity - public health and prevention agenda Local authority public health teams have National Child Measurement Programme duty, deliver weight management programmes and lead healthy schools agenda 43

44 6 Appendices Promoting parental responsibility and messages to parents through all partners, and national Change for Life campaigns Primary care role in promoting good health and identifying risk o Adults Individual responsibility - supported by national campaigns to promote 150 minutes of physical activity per week message Workplace health - Local authority public health teams working with employers to promote workplace policies (active travel, cycle to work, etc) Sport England have sport and recreation activity targets Local authorities as part of weight management/lifestyle services including exercise referral Primary care - promotion of good health for healthy adults - Making Every Contact Count - and health checks for target population Primary care, management of long term conditions - need better understanding of physical activity as treatment/management e.g. Walking Away from Diabetes in Leicester Secondary care - part of treatment pathways e.g. cardiac and pulmonary rehab, falls pathways, re-ablement, and part of discharge advice with respect to regaining/maintaining independence and ongoing rehabilitation post care episode - include in care plans and share with GP and social care teams Social care, supporting independent living 44

45 6 Appendices 6.3 Examples of existing provision The following examples were made known to the author of this report Leicestershire and Rutland County Sport Partnerships - Leicestershire County Council and Leicester-Shire & Rutland Sport, through development of a countywide sport and physical activity plan have developed a targeted approach aimed at sectors of the community who currently do little/no physical activity. The majority of the resources focus on targeted individuals / groups or communities: early years, inactive young people, people on low income, supporting Leicestershire families, people with disabilities, people with long term conditions, people with continuing healthcare services, families, and healthy weight. Each locality was required to submit a 'one stop sport and physical activity plan'. o Over 2million attendances recorded at sessions included in the sport & physical activity plans from o A joined up local offer, that focuses on inactive communities who can derive the greatest health benefit. o There has been a move to delivering more targeted interventions with the focus on impact rather than numbers. o Development of an evidence based approach supporting a local delivery model that offers: Targeted physical activity programmes, age and life stage appropriate, to a large and dispersed population. New targeted programmes, which can be adapted for use with a wide range of age groups and abilities. 45

46 6 Appendices A community based delivery model that will provide services in community venue. A community empowering approach, by training local community providers to deliver the programme and encourage user involvement to expand the programme within specific user-groups, through a cascade model of training. Interventions based on multi agency identified need and complimentary programmes of delivery. Planned action, integral to a local multi agency approach to public health brief interventions delivered by a workforce competent in community development/based approaches that focus on future sustainability and impact from the start. A planned promotional campaign to raise awareness of the health and wider benefits of sport and physical activity. o A number of specific interventions delivered are linked to support the prevention / management of: Mental health Dementia Long term conditions Coronary heart disease Cardiovascular disease Healthy weight Diabetes Falls prevention o Specific Referral based programmes include: Exercise referral Heartsmart 46

47 6 Appendices Weight management programmes such as LEAP & Flic Get Healthy, Get Into Sport DESMOND - Walking away from Diabetes Exercise (health) referral Tier 2 - Commissioned by Leicestershire County Council Public Health Directorate. Provided by North West Leicestershire District Council, Hinckley & Bosworth Borough Council, Oadby & Wigston Borough Council, Charnwood District Council, Melton Borough Council, Harborough District Council, Blaby District Council & Rutland County Council. 12 week programme offering tailored 1-1 and/or monitored support and assessment by a level 3 physical activity instructor. A growing range of appropriate physical activity programmes are offered to participants including gym based exercise, walking, swimming, and cycling. All referrals must classed as inactive*, be aged 16+ and exhibit at least one of the following risk factors for coronary heart disease (CHD) or metabolic syndrome : o Smoking o Family history of heart disease o High cholesterol levels o Obesity/overweight (BMI 25+) o Hypertension (140/90 to 179/99mmHg) o Controlled diabetes o Have been diagnosed with osteopenia or osteoporosis o Mental illness /psychiatric disorders where appropriate physical activity would be beneficial e.g. depressive disorders or anxiety disorders. o Locomotive and neurological disorders where appropriate physical activity would be beneficial o Controlled asthma 47

48 6 Appendices o Chronic pulmonary disease (subject to assessment by pulmonary rehabilitation specialist or equivalent) Heartsmart cardiac rehab referral (Tier 3) - Commissioned by Leicestershire County Council Public Health Directorate. Provided by North West Leicestershire District Council, Hinckley & Bosworth Borough Council, Oadby & Wigston Borough Council, Charnwood District Council, Melton Borough Council, Harborough District Council, Blaby District Council & Rutland County Council. 12 week programme offering tailored 1-1 and/or monitored support and assessment by a level 4 physical activity instructor. A growing range of appropriate physical activity programmes are offered to participants including gym based exercise, walking, swimming, and cycling. All referrals must classed as inactive*, be aged 16+ and have had a recent cardiac event or surgery (patients should be directed initially to phase IV by GP/cardiac rehabilitation services) Fundamental movement skills for 5-11 year olds - Commissioned by Leicestershire County Council Public Health Directorate. Provided by SAQ International Ltd. A pilot programme for seven primary schools in Leicestershire. The service aims to develop an early identification and intervention programme for young children with deficient fundamental movement skills in order to raise their physical abilities to the expected norm. Programmes work with pupils, teachers and parents. Trained interns embedded into schools to support the monitoring assessment and intervention programmes with pupils, to support and train school staff and parents, and intensively work with at risk children. 48

49 6 Appendices Northamptonshire Northamptonshire County Council - 20 million steps challenge September Derbyshire Mansfield District Council - Get Active Derbyshire Sport - The Active Derbyshire Plan including The Maternal Healthy Lifestyles Programme Nottinghamshire Get Active Mansfield (GP exercise referral - local authority run/providers) Healthy Change - a referral and support centre which offers ongoing over-the-phone support to citizens who want to make changes to the way they live. They can also arrange for people to attend one or more of the services below for free. Motivate offers a free 12 week weight management programme of exercise and nutritional advice aimed at overweight men, delivered by Notts County FC Football in the Community sports coaches. Active For Life (YMCA) offers a free 12-week exercise and motivational support programme to support people in becoming more active. Be Fit offers free gym use, fitness classes and swimming* at John Carroll, Victoria, and Southglade Leisure Centres between 10am-12pm and 1pm-3pm Monday to Saturday, for city residents who receive certain benefits. Best Foot Forward offers free weekly short guided health walks around various open spaces in the city. Ridewise (Cycling for Health) offers free cycle training sessions and organised group rides for people in Nottingham. 49