1. Physical Activity Creating A More Active England through Primary Care Vascular Learning Network – Manchester – 25 November 2008 Anthea Fitzsimons Physical Activity Projects Department of Health

2. Physical Activity 2 Activity has many health benefits Disease and disability caused by physical inactivity can cause serious and unnecessary human suffering and impaired quality of life 20-30 per cent reduced risk of premature death and up to 50 per cent reduced risk of major chronic disease Helps control body weight, and in combination with a healthy diet, contributes to weight loss Is effective in the treatment of clinical depression and has positive benefits for mental health

3. Physical Activity 3 And a positive effect on disease risk ChildhoodAdolescenceYoung adulthood Middle adulthood Old adulthood Impaired growth & development Risk factors Diseases and disorders Death RISK ACTIVE INACTIVE (Source: “At Least Five a Week” CMO 2004)

4. Physical Activity 4 We know that the cost of inactivity is high Costs to the NHS are increased by £1.48 billion p/a by physical inactivity. The costs of lost productivity to the wider economy have been estimated to be £5.42 billion from sickness absence and £1.04 billion from premature death of people of working age. Taken together, these costs may total over £8 billion. The economic benefits of physical activity extend beyond health to other sectors of the economy such as our industrial competitiveness, transport and environment. DH deriving national costs of inactivity at PCT level

5. Physical Activity 5 And there are direct health care costs attributable to inactivity Table: Direct Health Care Costs Attributable to Physical Inactivity in 1998 (Primary Prevention)

6. Physical Activity 6 The CMO recommendations for Active Living are ….at least 30 minutes a day of at least moderate intensity physical activity on 5 or more days of the week” Children and young people should achieve a total of at least 60 minutes of at least moderate intensity physical activity each day. These can be achieved either by doing all the daily activity in one session, or through several shorter bouts of activity of 10 minutes or more. Older people should take particular care to keep moving and retain their mobility through daily activity. Additionally, specific activities that promote improved strength, co- ordination and balance are particularly beneficial for older people

7. Physical Activity 7 However in 2006 only 40% of men and 28% of women achieved the CMO recommendations 2 HSE 2006

8. Physical Activity 8 Men reported higher levels of physical activity than women with participation generally decreasing with age 2 HSE 2006

9. Physical Activity 9 And trends have remained static for children’s activity levels 2 HSE 2006

10. Physical Activity 10 We know there are inequalities in participation 2 HSE 2006

11. Physical Activity 11 Are we getting the true picture? Health Survey for England captures physical activity across all domains for adults and children However, children (or their families) have a tendency to over-report their physical activity. Increasing evidence that accelerometry provides and objective, practical, accurate, and reliable means of quantifying amount and volume of physical activity. 2008 Health Survey for England is therefore using accelerometers in all under 11s and samples of 11-15 and the adult population. Objective fitness measure (step test) being used across the adult population. Data to be published in late 2009

12. Physical Activity 12 Other surveys such as Sport England Active People Survey measures sport and active recreation Largest survey of sport and active recreation in Europe Reports only sport and active recreation (but measures all walking and cycling) Main metric used for NI8 and LAP target of 2 million people more active – 3 x 30min 3 x 30 min target for sport and active recreation should not be confused with CMO recommendation But does not measure sub-30 minute bouts of activity nor does it report on or capture all everyday activity

13. Physical Activity 13 Healthy Weight, Healthy Lives focuses on reducing the rising tide of obesity and overweight……. “Our ambition is to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight. Our initial focus will be on children: by 2020, we aim to reduce the proportion of overweight and obese children to 2000 levels.” Theme 1 - Children: healthy growth and healthy weight Theme 2 - Promoting healthier food choices Theme 3 - Building physical activity into our lives Theme 4 - Creating incentives for better health Theme 5 - Personalised advice and support

14. Physical Activity 14 We are also investing £75m into an integrated marketing campaign

15. Physical Activity 15 We set out further commitments within the Legacy Action Plan Getting more people more active: help at least two million more people in England to be active by 2012 Initiatives are structured around a variety of themes 1.Healthier families 2.Targeting the least active 3.Removing the barriers and creating incentives to be more active 4.Creating a better environment for physical activity 5.Better coordination with Primary Care Trusts Action to achieve the target will be driven by a range of government departments and overseen by the 2012 Programme Board

16. Physical Activity 16 Going further still our new Physical Activity Plan will set out how we will deliver a more active nation by Providing guidance on how local authorities and PCTs can determine and respond to the needs of their local populations by using local, regional and national levers for physical activity Demonstrating the costs of inactivity for local health economies Supporting the seamless delivery of sport and physical activity at the grass roots Bringing together existing government commitments including Healthy Weight, Healthy Lives and the 2012 Legacy Action plan and set out how we will contribute to the ambition of 2 million people more active by 2012 Set out how we intend to develop Change 4 Life and the incorporation of activity into our everyday lives Signalling more support for ‘everyday’ forms of activity, such as active travel, recreation, social dance, gardening or simply parents playing with their children

17. Physical Activity 17 Introducing Let’s Get Moving Targeted brief intervention Sedentary adults aged 16 – 74 Mainstream PA advice and recommendations Delivered in Primary Care Health Care Practitioners Designed with a view to national roll-out

18. Physical Activity 18 When NICE reviewed the evidence it recommended that Primary care practitioners should take the opportunity, whenever possible, to: identify inactive adults through the use of a validated screening tool (GPPAQ) advise them to aim for 5 x 30 take into account the individual’s needs, preferences and circumstances agree goals with them provide written information about the benefits of activity and the local opportunities to be active follow them up at appropriate intervals over a 3 to 6 month period. NICE Public Health Intervention Guidance: Four commonly used methods to increase activity (2006)

19. Physical Activity 19 Physical Activity Risk Assessment and Management features prominently in the Checks Programme

20. Physical Activity 20 GPPAQ as an effective screening tool As physical inactivity is a major public health problem, screening for physical inactivity in all adults is generally appropriate Developed for use in routine general practice Algorithm assigns patients into one of four categories Designed to take no longer than one minute to complete Intended to be self-explanatory Categories can be cross referenced to new read codes GPPAQ was evaluated for use in patients aged 16-74 years who were free from longstanding illness or disability that prevented them from engaging in a physically active lifestyle. It is an essential part of Let’s Get Moving and has been shown to be a legitimate tool to raise the issue sedentary of lifestyles with patients.

21. Physical Activity 21 Let’s Get Moving has four distinct steps COMPLETION NOT INTERESTED OPPORTUNISTIC NOT ELIGIBLE PATHWAY COMPLETE SCREENING INTERVENTION DELIVERY CONDUCT BI DISEASE REGISTER GPPAQ GPPAQ CLASSIFICATION ASSESSMENT OF PATIENTS ELIGIBILTY & APPROPRIATENESS ELIGIBLE ASSESS INTEREST INSUFFICIENTLY ACTIVE ASSESS WALKING ACTIVE INTERESTED BOOK SEPARATE BI CONSULT READY TO CHANGE NOT READY TO CHANGE Reinforce PA message Invitation to return at a later stage BRIEF INTERVENTION (MOTIVATIONAL INTERVIEW) RISK STRATIFY AGREE GOALS Raise awareness of PA Work through Lets Get Moving Support Pack SIGN POST TO ACTIVITIES EXIT PATHWAY EXIT PATHWAY GPPAQ not Completed EXIT PATHWAY CONDITION UNLIMITED GREEN EXERCISE WALK GROUP SPORTS CLUB LEISURE CENTRE COMMUNITY CENTRE CLASS PROGRAMMES Structured Activity ACTIVE TRAVEL PEDOMETER PROGRAMME ACTIVE WORKPLACE PARKS & GREEN SPACES ACTIVE DAILY LIVING DANCE Self-directed Activity MASS PARTICIPATION EVENTS CLINICAL NEED CONDITION SPECIFIC PROGRAMME EXERCISE REFERRAL Supervised Activity Book follow-up for three months time PATIENT FOLLOW-UP AT 3 MONTHS PATIENT FOLLOW-UP AT 6 MONTHS FOLLOW-UP APPOINTMENT RESET GOALS COACH & COUNSEL RELAPSE MAINTENANCE REINFORCE BEHAVIOUR RESET GOALS REVIEW GOALS ELIGIBLE NOT ELIGIBLE EXIT PATHWAY

22. Physical Activity 22 CONDUCT BI DISEASE REGISTER GPPAQ GPPAQ CLASSIFICATION ASSESSMENT OF PATIENTS ELIGIBILTY & APPROPRIATENESS ELIGIBLE ASSESS INTEREST INSUFFICIENTLY ACTIVE ASSESS WALKING ACTIVE INTERESTED BOOK SEPARATE BI CONSULT EXIT PATHWAY GPPAQ not Completed EXIT PATHWAY NOT ELIGIBLE NOT INTERESTED OPPORTUNISTIC Recruitment (pilot) Opportunistic Disease Register Eligible/ appropriate Contra-indications Context of consultation Age Assessment (GPPAQ + walking) Patient interested How a patient enters the pathway

23. Physical Activity 23 The intervention is shaped by the patient READY TO CHANGE NOT READY TO CHANGE Reinforce PA message Invitation to return at a later stage BRIEF INTERVENTION (MOTIVATIONAL INTERVIEW) RISK STRATIFY AGREE GOALS Raise awareness of PA Work through Lets Get Moving Support Pack SIGN POST TO ACTIVITIES EXIT PATHWAY Use of MI principles Patient self-report PA level Patient Readiness to Change Importance rating of PA Confidence rating to change behaviour Risk stratification Goal setting Signposting Let’s Get Moving Pack

24. Physical Activity 24 Let’s Get Moving Pack based on principles of behaviour change

25. Physical Activity 25 Armed with goals the patient is directed to activity CONDITION UNLIMITED GREEN EXERCISE WALK GROUP SPORTS CLUB LEISURE CENTRE COMMUNITY CENTRE CLASS PROGRAMMES Structured Activity ACTIVE TRAVEL PEDOMETER PROGRAMME ACTIVE WORKPLACE PARKS & GREEN SPACES ACTIVE DAILY LIVING DANCE Self-directed Activity MASS PARTICIPATION EVENTS CLINICAL NEED CONDITION SPECIFIC PROGRAMME EXERCISE REFERRAL Supervis ed Activity Low or Medium Risk Structured Activity Self Directed Activity High Risk based on clinical need Clinical exercise programmes

26. Physical Activity 26 Follow-up is an essential part Book follow-up for three months time PATIENT FOLLOW-UP AT 3 MONTHS PATHWAY COMPLETE PATIENT FOLLOW-UP AT 6 MONTHS FOLLOW-UP APPOINTMENT RESET GOALS COACH & COUNSEL RELAPSE MAINTENANCE REINFORCE BEHAVIOUR RESET GOALS REVIEW GOALS ELIGIBLE NOT ELIGIBLE EXIT PATHWAY 3 and 6 month follow-up Attempts to increase PA are reviewed Patient self-report PA level Re-assessment of eligibility New goals set

27. Physical Activity 27 Our evaluation looked at COST and FEASIBILITY To investigate the feasibility of a physical activity care pathway in general practice and establish a best practice model or standard pathway, based upon the key attributes found to be essential for successful delivery Three primary objectives:  To determine benefits of PACP for both patients and practices  To investigate the feasibility of alternative delivery models  To determine the cost of implementation

28. Physical Activity 28 Who’s involved? London Pilot  14 practices across 7 PCTs  Patient recruitment commenced Oct 2007  Over 1200 patients screened  Evaluated by the BHF National Centre for Physical Activity and Health (Loughborough University)  Report due Jan 2009 DH lead in partnership with NHS London, Natural England, Sport England

29. Physical Activity 29 Evaluation Methods EMIS Templates MIQUEST Audit Weekly Contact with Practitioners Focus Groups Economic Analysis

30. Physical Activity 30

31. Physical Activity 31 Looking ahead to 2009 National roll-out of a standard PACP model GPPAQ embedded in GP software systems Dissemination of evaluation findings & launch event (April tbc) Production of a commissioning toolkit Further development of the Let’s Get Moving resources Further evaluation? Creating links with related DH programmes e.g. obesity, vascular, COPD, walking

32. Physical Activity 32

33. Physical Activity 33 Contact Details Anthea Fitzsimons Physical Activity Team Department of Health Anthea.Fitzsimons@dh.gsi.gov.uk