The Northumberland Exercise Referral Scheme
(Durham University, Department of Sport and Exercise Sciences)
It is a misconception that exercise referral doesn’t work! The Northumberland Exercise Referral Scheme (ERS) was set up by Coral Hanson, then based in Active Northumberland, who managed the service across nine leisure sites. Active Northumberland were keen to learn more about what worked, why and for whom. Drs Coral Hanson, Caroline Dodd-Reynolds and Emily Oliver worked with patients, commissioners and providers through Active Northumberland to understand who benefits from physical activity referral, who misses out, why, and how we can work to improve service delivery.
THE EVIDENCE BASED APPROACH
Outcomes – Develop Shared Local Strategic Outcomes for Your Place
Our desired outcome was ultimately to improve uptake and retention of patients referred to the scheme, and to improve accessibility of the service for those who may struggle, such as men, younger adults, those from lower socioeconomic status areas and those with excess weight.
We set out to do this by:
- Informing future physical activity referral pathways and weight management pathways in the county by rigorously evaluating the ERS scheme in Northumberland. ERS are not generally set up as weight management schemes, rather they focus on providing an opportunity for physical activity over ~12 weeks. We explored how well this worked as a weight management scheme, as well as for increasing physical activity and reducing existing physical activity and weight inequalities.
- Informing and influencing researchers, policy makers, and service delivery teams by publishing peer-reviewed journal articles.
Insight – Understand Your Community and Your Place
We used socioeconomic and health data to understand the area. Northumberland is a county with pockets of particularly high and mixed deprivation. Unemployment is higher than the national average, and excess weight is also higher than the national average. We strongly believe that place-based insight is crucial in adapting services and scaling up delivery models elsewhere. Standard randomised controlled trials tell us lots about efficacy, or ‘what works’ but physical activity is a behaviour, and people’s relationships with physical activity are complex. Therefore, we worked closely with Coral and her team to co-design evaluations that would be useful in informing their local service delivery and to share good practice across leisure sites.
Interventions – Identify How the Outcomes Can be Achieved Sustainably
The intervention was a 24-week referral scheme. A large database was established by the ERS provider, at the commencement of the scheme. By March 2014, over 9000 people had been referred and were encouraged to attend two supervised exercise sessions per week. Of those, 40% were referred for excess weight, usually by their GP.
Commitment – Secure Investment Commitment to Outcome Delivery
Whilst continuing her full-time role, Coral began a part-time PhD at Durham University, funded by her employers and supervised by Caroline and Emily. The PhD programme was supported by Active Northumberland, whilst other aspects of evaluation were supported by the Wolfson Research Institute for Health and Wellbeing.
Evaluation – Understand the Impact of Your Work
Coral undertook a mixed-methods evaluation of the scheme to understand what worked and for whom, and why. Caroline and Emily also explored referral patterns related to social and health inequalities.
Exercise referral can indeed work – if it is appropriately set up, evaluated and understood. The scheme led to moderate weight loss and improved and sustained physical activity, for those who adhered. Once people began the scheme, it operated similarly well regardless of factors such as age, gender and employment status. However, we noted that those living in lower socioeconomic status (SES) areas were more likely to experience lower physical activity relative to other SES groups, despite the intervention. Expectations of the scheme were important to those referred (e.g. was it like a dietary prescription?) and impacted on experiences, whilst personal and social support proved important at different points in the referral journey. Read more about Durham’s physical activity evaluation work here.
We can better understand ‘effectiveness’ in public health research by working in community settings. Quantitative (numerical) data is still really important, but we also need to ask those referrals about their experiences, including those who struggle to engage. Once we understand the needs of our community, we can adapt existing services to optimise physical activity and health. Collaborations in community settings are essential in informing public health and clinical practice. They provide a clear window through which to examine outcomes and reasons for those outcomes, particularly given the numerous and wide-ranging ERS currently operating internationally. Opportunities for practitioners to be embedded in research, or researchers to be embedded in practice can improve understanding and improve outcomes. We really welcome research applications from those working in the physical activity sector so do get in touch if you are interested in finding out more!
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