There is a continued national public health strategic focus on increasing physical activity at a population level1 and primary care is being called on to play a central role in this drive,2 with the Royal College of General Practitioners (RCGP) set to appoint the first clinical champion for physical activity. Nationally Public Health England (PHE)3 and globally the World Health Organization4 have highlighted the importance of increasing physical activity and reducing sedentary time. Guidelines and recommendations from the Department of Health5 and the National Institute for Health and Care Excellence6 also emphasise the importance of physical activity promotion in primary care. GPs’ workloads are already ballooning; but with the right knowledge, skills, and support, prioritising physical activity could potentially have a positive impact on our patients health.7
BENEFITS OF PHYSICAL ACTIVITY
Physical activity is as important as healthy lifestyle choices such as diet, smoking cessation, and sensible alcohol intake. It is estimated that physical inactivity is directly responsible for up to 10% of noncommunicable diseases and another 9% of premature mortalities.8 Daily physical activity totalling 150 minutes of moderate intensity or 75 minutes of vigorous intensity per week9 can help prevent many noncommunicable diseases: a 20–35% reduction in cardiovascular disease and premature mortality risk with a reduction in the risk of other diseases including type 2 diabetes (35–50%) and breast and colon cancer (20–50%) is hard to ignore.10 Physical activity is also beneficial for most long-term conditions and comparable with pharmacological therapy in outcomes for many conditions such as mortality in stroke, heart failure, and patients with pre-diabetes11 with the additional preventative effects on other diseases. There is also evidence for improved morbidity and mortality outcomes in cancer patients.12 Despite this evidence, approximately 40% of UK adults are insufficiently active to enjoy significant health benefits.13
THE ROLE OF HEALTH PROFESSIONALS
Health professionals can have a positive impact on patient behaviour in a consultation through brief physical activity advice interventions: the number needed to treat (NNT) for sustained physical activity at 12 months7 is 12 compared to an NNT of 35–120 for brief smoking cessation advice,14 although differing populations and study methodologies make these figures difficult to compare directly. General practice is under extreme pressure with short consultation times, so understandably physical activity discussions are not the focus of most primary care consultations. Making use of other members of the primary care team to provide physical activity interventions via motivational interviewing behaviour consultation skills may be more time and cost effective. Even so, the evidence suggests that barriers to addressing physical activity more commonly in consultations may include a lack of knowledge and confidence in promoting physical activity,15 exacerbated by the fact that exercise medicine is not routinely taught in many medical schools despite freely available resources,16 and a limited focus in the RCGP curriculum.
INITIATIVES TO INCREASE PHYSICAL ACTIVITY
In addition to physical activity advice during a consultation, there are other promising initiatives to increase patient physical activity. These include Macmillan Cancer Support physical activity project ‘Move More Scotland’ embedding high-quality physical activity resources into cancer care,17 such as stepped behaviour change counselling and follow-up support. There is huge potential to use mobile phone apps and wearable devices that track patient physical activity to encourage further physical activity. The PACE-UP trial has successfully used pedometer and accelerometers with individual nurse support within general practice to increase patient physical activity18 and the use of competitions such as the community physical activity challenges like Beat The Street are promising (https://www.beatthestreet.me/UserPortal/Default). Accessible online resources for patients such as the ‘Benefit from Activity’ website (http://www.benefitfromactivity.org.uk/), which provides education, practical physical activity resources, and links to other organisations and the Age UK ‘Generation Games’ project in Oxfordshire, which also includes local exercise classes and activities (https://generationgames.org.uk/). However, many physical activity initiatives lack evidence of cost-effectiveness and health benefits, particularly over the longer-term. Even exercise referral schemes, which are commonplace in primary care, are not broadly recommended for sedentary individuals without comorbidities because their benefit remains equivocal in many instances.19
The RCGP has recently chosen physical activity and lifestyle as one of its clinical priorities for the next 3 years.20 A clinical champion will plan, implement, and deliver innovative programmes to transform the delivery of physical activity promotion in general practice.20 This should help to break down some of the barriers preventing a greater focus on physical activity in primary care consultations by promoting GP learning resources such as Motivate2Move (http://gpcpd.walesdeanery.org/index.php/welcome-to-motivate-2-move) and educational initiatives to ensure a greater awareness of the benefits of physical activity. Many physical activity initiatives in primary care are still in their infancy and the clinical champion will be able to direct GPs towards core and locally enhanced services and initiatives with evidence of greatest effectiveness to commission.
IMPACT ON SOCIETAL CULTURE SHIFT
As well as the direct impact on patient physical activity through consultations and commissioning, GPs should also consider the broader impact they can have in developing a societal culture shift towards becoming more physically active.Healthcare professionals are some of the most trusted individuals in society21 and have an important role to play in influencing behaviour change in patients and their families. While the time they can spend advising individual patients on physical activity is limited, improving patient awareness and reinforcing a physical activity message consistently, particularly outside of the consulting room, is important and could have significant long-term impact. This has been demonstrated with the anti-smoking message with regular questions and advice about smoking status backed up with waiting room and website information. Recording patients’ physical activity levels and being able to signpost patients to appropriate physical activity resources or physical activity opportunities locally can help to highlight its importance. Even though the long-term impact of primary care on culture change and physical activity level in patients is challenging to measure, we shouldn’t underestimate or neglect it.
General practice initiatives are only one small piece of the UK physical activity promotion jigsaw,22 a fact acknowledged by PHE.3 Sporting bodies, schools, planning authorities responsible for facilities and infrastructure, commercial enterprise, and a strong voice from government are all vital ingredients in the drive to improve physical activity and allow incorporation of physical activity into daily life. However, general practice is still an important piece of the jigsaw and its role should not be underestimated even in times of increased pressure on primary care resources. GPs have the trust and ongoing relationship with patients and their families and the long-term health impact of a more physically active population could be enormous. The RCGP’s new clinical champion will need some skilful joined up thinking to coordinate some of the more promising physical activity initiatives and to liaise with multiple stakeholders during the next 3 years to make the most of this opportunity and ensure general practice is able to play its part in the promotion of physical activity.
Notes
Provenance
Commissioned; externally peer reviewed.
- © British Journal of General Practice 2016