A total of 2233 referrals were made between July 2009 and October 2010. A total of 19% (n=422) referrals were non-starters. Of these, 409 did not attend a consultation and 13 were excluded after the prescheme consultation. Eighty-one per cent (n=1811) of referrals were admitted to the scheme after the initial assessment (uptake). Of these 46.5% (n=843) dropped out in the first 12 weeks, 53.5% (n=968) attended the 12-week consultation, 10.5% (n=191) dropped out between weeks 13 and 24 and 42.9% (n=777) attended the 24-week consultation.
Table 2 shows personal and referral characteristics of participants. Referrals were predominantly female (59%), with a mean age of 53 years (15.9 SD). The main referrers were general practitioners (58%, n=1278) and the most common reasons for referral were overweight/obesity (42%, n=913) and cardiovascular disease primary/secondary prevention (CVD) (30%, n=649).
Descriptive characteristics of referrals
Differences in personal and referral characteristics between non-starters and starters
Descriptive characteristics of referrals can be seen in table 2. There were significant differences in demographics (age t(2231) =−9.60, p<0.001; IMD t(2211) =−5.40, p<0.001; employment status X2=40.43, p<0.001) and in referral characteristics (reason for referral X2=31.2, p<0.001, secondary reason for referral X2=20.8, p<0.001 and leisure site X2=38.0, p<0.001) for starters compared to non-starters.
Characteristics associated with uptake, adherence and completion
A logistic regression analysis was conducted to predict uptake of the ERS using age, gender, IMD quintile, reason for referral, secondary reason for referral, profession of referrer and leisure site as predictors. A test of the full model against a constant only model was statistically significant, indicating that the predictors as a set reliably distinguished between acceptors and decliners of the offer (X2(31) =168.53, p<0.001).
Nagelkerke's R2 of 0.12 and Cox & Snell R2 of 0.08 indicated an adequate relationship between prediction and grouping. Prediction success overall was 81.5% (99.5% for starters and 4.3% for non-starters). The Wald criterion demonstrated that age (35–44 years, B=0.705, SE=0.247, 45–54 years, B=0.657, SE=0.240, 55–64 years, B=1.113, SE=0.249, 65–74 years, B=1.429, SE=0.274, 75+ years, B=2.002, SE=0.421), gender (female B=0.341, SE=0.122), IMD quintile (61–80%, B=0.533, SE=0.215, 81–100% least deprived B=0.348, SE=0.204), secondary reason for referral (metabolic/endocrine B=1.104, SE=0.409) and leisure site (site F, B=0.855, SE=0.304, site H, B=0.925, SE=0.387, site I B=0.664, SE=0.315) made significant contributions to the model.
A second logistic regression analysis was conducted to predict 12-week adherence among starters using the same predictors as in regression one, but with the addition of prescheme BMI. A test of the full model against a constant only model was statistically significant, indicating that the predictors as a set reliably distinguished between dropouts and 12-week adherers (X2(34)=261.82, p<0.001).
Nagelkerke's R2 of 0.19 and Cox & Snell R2 of 0.14 indicated an adequate relationship between prediction and grouping. Prediction success overall was 66.9% (62.1% for dropouts and 70.8% for adherers). The Wald criterion demonstrated that age (55–64 years, B=1.382, SE=0.302, 65–74 years, B=1.734, SE=0.302, 75+ years, B=1.173, SE=0.354), IMD (61–80%, B=0.412, SE=0.195, 81–100% least deprived B=0.671, SE=0.199), profession of referrer (cardiac rehabilitation nurse, B=0.829, SE=0.254), BMI (35+ kg/m2 B=−0.437, SE=0.218) and leisure site (site G, B=−1.393, SE=0.391, site H, B=−1.185, SE=0.341, site I, B=−0.961, SE=0.299) made significant contributions to the model.
The final logistic regression was conducted to predict 24-week completion among 12-week adherers using the same predictors as regression two. A test of the full model against a constant only model was statistically significant, indicating that the predictors as a set reliably distinguished between those who dropped out between 12–24 weeks and completers (X2(34)=159.16, p<0.001).
Nagelkerke's R2 of 0.25 and Cox & Snell R2 of 0.19 indicated an adequate relationship between prediction and grouping. Prediction success overall was 82.2% (24.2% for dropouts and 96.5% for adherers). The Wald criterion demonstrated that BMI (30–34.9 kg/m2 B=−1.164, SE=0.377, 35+ kg/m2 B=−0.921, SE=0.395) and leisure site (site G, B=−1.336, SE=0.377, site H, B=−2.102, SE=0.533, site I, B=−1.709, SE=0.473) made significant contributions to the model (table 3).
Binary logistic regression outcomes
Physical activity levels
Self-reported physical activity for those who completed the scheme was measured through the GLTEQ26 prescheme and postscheme. Mean prescheme weekly activity scores were 17.43 units/week (15.82 SD) and postscheme scores were 27.11 units/week (20.46 SD). This equated to 52 min of moderate activity per week prescheme and 81 min postscheme, (a mean increase in moderate activity of 29 min/week). Participants who completed significantly increased their self-reported physical activity levels (t(638)= −11.55, p<0.001).
Attendance at supervised ERS sessions
Mean attendance across sites for dropouts before 12 weeks was 4.28 sessions (5.68 SD), for 12-week adherers was 13.06 sessions (9.2 SD) and for completers was 22.87 sessions (12.47 SD). For completers, this equated to 47.7% of potential attendances (maximum 48), however, there were large variations between sites. Highest mean attendance for completers at a single site (A) was 31.18 (11.87 SD) sessions and the lowest (H) 15.37 (6.69 SD) sessions.
Increasing how much physical activity someone does can significantly improve both their physical and mental wellbeing and reduce illnesses and disease throughout life. It can also improve life expectancy.
For example, physical activity can help prevent and manage more than 20 conditions and diseases including coronary heart disease, some cancers, diabetes, musculoskeletal disorders, mild to moderate depression and obesity (Start active, stay active: a report on physical activity from the four home countries' chief medical officers Department of Health 2011). Evidence also indicates that being sedentary is an independent risk factor for certain diseases such as coronary heart disease and type 2 diabetes, even when achieving the recommended physical activity levels (Lee et al. 2012).
Most adults in England do not meet the national recommended levels of physical activity. In 2008, based on self-reporting, 39% of men and 29% of women aged 16 and older met the recommended minimum (Health Survey for England 2008: physical activity and fitness Health and Social Care Information Centre 2009).
In 2013, The Health Survey for England (population chapter, Health and Social Care Information Centre 2013) re-analysed the 2008 data using the revised national recommendations published in 2011 (see 'National guidelines, resources and indicators' below). It estimated that 65–66% of men and 53–56% of women were meeting the new recommendations in 2008 – and probably continued to do so up to 2012.
Physical activity levels vary according to income, gender, age, ethnicity and disability. Generally, women are less active than men and people tend to be less active as they get older. Leisure time physical activity levels are also lower among certain minority ethnic groups, people from lower socioeconomic groups and people with disabilities ('Start active, stay active: a report on physical activity from the four home countries' chief medical officers').
During 2007/08, an estimated 300 million consultations took place with primary care practitioners, with the average patient attending 5.4 consultations (Trends in consultation rates in general practice: 1995/1996 to 2008/2009: analysis of the QRESEARCH database QRESEARCH and Health and Social Care Information Centre 2008). Every consultation provides an opportunity to promote physical activity (Boyce et al. 2008).
Lack of physical activity: the costs
Public Health England's Health impact of physical inactivity estimates that low levels of physically activity could be the cause of up to 36,815 premature deaths in England a year.
In 2006/07 physical inactivity cost the NHS an estimated £0.9 billion, based on the occurrence of diseases that can be prevented by being physically active (Scarborough et al. 2011). This is a conservative estimate because other health problems, such as osteoporosis and poor mental health, can also be exacerbated by a lack of exercise. There are also wider economic costs, for example sickness absence from work, estimated at £5.5 billion per year.
In 2008 the Department of Health's Be active, be healthy estimated that the average cost of physical inactivity for every primary care trust in England was £5 million.
National guidelines, resources and indicators
In 2001, the Department of Health developed the National quality assurance framework for exercise referral. It focuses primarily on schemes that take place in leisure centres or gyms and involve supervised exercise programmes. This framework aimed to improve existing schemes and help develop new ones. It is currently being updated.
In 2010 the British Heart Foundation National Centre for Physical Activity and Health published an exercise referral toolkit advising how exercise referral schemes could be designed, implemented and evaluated.
In 2011, the Chief Medical Officers of England, Scotland, Wales and Northern Ireland issued joint UK physical activity guidelines for people of all ages ('Start active, stay active: a report on physical activity from the four home countries' chief medical officers').
For adults, the guidelines recommend being active daily and accumulating at least 150 minutes of moderate-intensity activity, or 75 minutes of vigorous activity, in bouts of 10 minutes or more during each week. The guidelines also recommend avoiding being sedentary for prolonged periods (such as sitting for long periods of time). There are additional recommendations on strength for all groups, and to help improve balance among older people.
To help achieve the recommendations, the Department of Health has recently updated its Let's get moving physical activity care pathway. This is a systematic approach to identifying and supporting adults who are not currently meeting the national recommended level of physical activity.
The revised Department of Health Public health outcomes framework for England, 2013–2016 also highlights the importance of encouraging physical activity and reducing sedentary behaviour (see domain 2).