Physical activity promotion by GPs: a cross-sectional survey in England

Summary

PA is important for the prevention and management of numerous health conditions. Primary care settings have an important role to play in supporting people to be active as part of a whole-system approach.⁵ This study aimed to describe GPs’ experiences of promoting PA within the primary care setting.

Findings show that almost all GP responders (98.9%) believed that PA is important in the prevention and management of health conditions. Although many were not familiar with the CMO guidance on PA, the majority reported feeling confident raising the topic of PA with their patients. Awareness and use of PA tools to assess a patient’s PA varied; the most widely known and used tool was the GPPAQ. Many of the other available tools were not known to GPs. The most widely cited barrier to discussing PA with patients was a lack of time; this was underscored through analysis of open-text responses. The most common facilitators were GPs’ own PA behaviour and awareness of local PA opportunities. Awareness of, and engagement with, PA-related training was generally low. With regard to PA campaigns and support tools, ‘Couch to 5k’ and the ‘parkrun practice’ initiatives were the most widely known and used. Finally, GP responders perceived the NICE website to be the most trusted source of information, and blogs were perceived as the least trusted.

Strengths and limitations

This survey accessed a large sample of GPs as part of an omnibus survey that was not explicitly about PA. This may reduce the bias associated with attracting only PA advocates. The sample was self-selected, in that GPs opted-in to the omnibus survey. It was noted that GPs in training (GP registrars) were underrepresented with a predominance of older, more experienced GP responders. Data collection was undertaken in January 2021 in the midst of the COVID-19 pandemic, which might have impacted on recruitment and responses.

Comparison with existing literature

The findings build on those of Chatterjee et al,¹⁵ providing an update on GPs’ perspectives on PA promotion within the primary care context. Comparisons must be interpreted with caution, however: despite using similar methods, the wording of the questions was changed along with response options, making direct comparison inappropriate. Instead noteworthy trends are highlighted.

The findings of the present study suggest that 35.7% of responders were at least somewhat familiar with the CMO guidance on PA, which is a greater proportion of responders than in 2017 when only 20% were familiar. The proportion of GPs who reported feeling confident to discuss PA with patients is also greater than reported in the 2017 survey and the proportion feeling unconfident decreased. Previous literature has indicated that primary care providers might lack knowledge and confidence in discussing and promoting PA among patients.^26–28 However, the current findings suggest that, while familiarity with the CMO PA guidance remains low, three-quarters of GPs felt confident to discuss PA with patients.

The findings regarding use of GPPAQ to assess PA in primary care mirror those of Chatterjee et al; ¹⁵ it remains the best-known tool (49%) but use remains relatively low (24%). This warrants further exploration; pragmatic, integrated assessment tools could facilitate conversations about PA and help to make it ‘part of the process’ within clinical practice. However, despite being launched in 2006, findings suggest that the GPPAQ is not part of routine practice for many GPs.

When asked about specific PA tools and campaigns that were used in practice ‘Couch to 5k’ was the best known (78%) followed by the ‘parkrun practice’ initiative (66%). This suggests significant reach of these initiatives, perhaps explained by the partnerships these programmes have with NHS and Royal College of General Practitioners, respectively. It is surprising that awareness of social prescribing was not higher, with only 36% of GPs reporting that they were aware of it. This may reflect the fact that it is relatively early in the implementation of social prescribing and the extent to which it is embedded varies regionally.

Lack of time was the most reported barrier to discussing PA with patients, a finding that reflects existing literature.^29,30 In the UK, the GP workload is the highest it has ever been, and existing time constraints have been compounded by increased pressure on primary care owing to COVID-19.¹⁷ As the primary care system reconfigures, there is opportunity to embed PA across primary care. This notion speaks to the growing body of evidence that engaging the whole system is the only viable way to create meaningful change in population PA levels, as noted by McAuley et al:³¹

'Doctors can be trained to deliver opportunistic advice on behaviour change, including exercise, but that doesn't necessarily change population levels of inactivity if efforts are sporadic, confined to motivated practitioners, or isolated from the societal factors that cue inactive choices.'

Another key barrier to PA promotion that was frequently cited by GPs was the patient's first language not being English. People who cannot speak English well are more likely to be in poor health and experience a more rapid decline of good health by age.³² Nobles et al ³³ highlighted the need for culturally tailored language when communicating PA messages to underserved communities. This finding warrants further investigation owing to its potential to further exacerbate health inequalities.

Almost half of GP responders (45.9%) cited that concern from the patient about perceived risks of taking up PA acts as a barrier to advising patients on PA. This underscores the importance of the role of primary care clinicians in helping patients to interpret risk appropriately and in facilitating conversations that help patients to balance the inherent risks of physical inactivity with risks associated with increases in PA. Such conversations will be helped by the recent consensus statement confirming the low risk associated with PA for most people living with long-term conditions from Reid et al.³⁴

Implications for research and practice

The headline finding that GPs value PA is positive. There are opportunities to explore how PA promotion can be made easier for GPs in the face of ongoing barriers. In addition to well-known barriers,^28,29 the present research also suggests additional barriers include communicating effectively with people who cannot speak English. If communication issues prevent GPs from promoting PA to people known to experience worse health, it has the potential to widen existing health inequalities and should be a priority for further research and action.

The findings suggest that promotion of PA in primary care could be facilitated through the design of tools that are intuitive, integrate with existing systems, and enable quick assessment of PA. This could be helpfully explored, as could the development of appropriate training of GPs in the promotion of PA. The findings also illustrate that community PA offers, such as ‘parkrun practice’ and ‘Couch to 5k’ are widely used by GPs. GPs clearly feel the need to know more about local offers; however, as social prescribing is scaled-up and link workers are embedded, it may enable GPs to reinforce critical messaging and then hand over to team members who have current community connections.

GPs need to be supported by other members of the primary care team and the wider community, and enabled by systems and processes within primary care if they are to be effective in promoting PA. The individual action of GPs could be enhanced by stronger and closer connections between primary care and local authorities, PA providers, public health teams, Active Partnerships, integrated care systems, and other key parts of the broader system. As the landscape of primary care changes, a joined-up approach to embedding PA promotion across primary care is needed.