What is the Exercise Referral Scheme? (ERS)

Exercise referral schemes were introduced in the UK in the early 1990s (Morgan et al., 2016) and were adopted by most primary care trusts as an element of care packages for clients who were not achieving the chief medical officer’s recommendations of 150 mins of moderate exercise per week (O'Donovan et al., 2010), who were also at risk of developing non communicable diseases (Kruk, 2014; Morgan, 2005). The scheme was rolled out in response to the concerning trend of sedentary behaviour and the correlation between diet and inflammatory and comorbidity diseases (Public Health England, 2016; Wanless, 2004). It is accepted that exercise prevents disease and improves physiological and psychosocial health (Hassmen et al., 2000).

What are it’s aims?

The scheme’s aims are to provide early intervention support for individuals who have or are at risk of non-communicable diseases, by providing a pathway into regular, part funded exercise with a Physical therapist. This usually takes place at a local gym, which, unfortunately, is a well evidenced barrier to exercise (Glowacki, 2017). A further aim of ERS is that the individual would use the support to gain knowledge and confidence with exercise and continue to adhere to it long-term, thus saving the NHS resources and money spent dealing with chronic health issues due to lifestyle habits and sedentary behaviour. This cost the NHS £0.9 billion in 2019 (Bird et al,.2021).

What are the issues?

The effectiveness of the scheme’s benefits over the past 20 years is not well evidenced (Williams et al., 2007). There is significant research to suggest that the scheme lacks long-term adherence (Pavey et al., 2011). One systematic review found that Ireland’s scheme was more effective in long-term adherence due to the scheme running for a minimum of 12 weeks and implementing behaviour change strategies (Rowley et al., 2018). Studies have highlighted that GPs often feel referral for exercise is outside of their remit and many did not advocate the benefits or feel the scheme worked (Graham et al., 2005). Other consistent and significant issues were the lack of knowledge, training and implementation of behaviour change science within schemes which referred individuals to local sports centres (Moore et al., 2011).

It is difficult to evidence the cost effectiveness due to the heterogeneous nature of outcomes measured as well as the scheme being called a variety of different names, different implementation processes, and different interpretation of the National Quality Assurance Framework (Henderson et al., 2018). As such, success outcomes are difficult to measure because providers may interpret the schemes based on different criteria (Rowley et al., 2018). This results in research into the success of the schemes being influenced by the separate health contexts within which the schemes are located (e.g., NHS v Sports Centres) (Rowley et al., 2018).

The referral scheme appears to be a good, logical theory, but due to the pathway into leisure centres, specifically, it has been found to be a waste money (Henderson et al., 2018 The (Dugdill et al., 2005) studies have found that referrals to leisure centres evidenced a 80% drop out before completion, however, data is difficult to collect within the schemes and comparisons across groups have been complex, due to the referral pathways, variables within client groups (exercise referral for different diseases) and whether there has been multi agency involvement.

The future possibilities

Parkrun has organically grown into a substantial health community and has since grown into Park yoga and other activities (Stevinson et al., 2015). Whilst it could be a successful pathway for ERS it was found to attract groups who were white ethnicity, with high socioeconomic status, with a high social network (Cleland, 2019), and, therefore, not reaching the intended inactive groups, with health issues and physical barriers. It could still offer an opportunity for Exercise specialists and social prescribers to support clients into the run during the latter ERS programme for additional move-on exercise support (Tobin, 2018; Quirk & Haake, 2021).

Fox 1997, showed that schemes which refer to exercise specialists, nurses and behaviour change professionals, who can provide the needed holistic model to tackle all aspects of the issue, are successful, whereas schemes within local sport centres may lack the motivational and social support needed to promote adherence to long term health change. Schemes which refer within specialist care with an aim to regain independence appear to have better outcomes (Sharma et al., 2012). Research into the effectiveness of exercise types and doses would be advantageous for standardisation and guidelines for exercise specialists to implement on the ground within the UK (Singh, 2002).

Sweden has a very successful exercise referral scheme showing 73% improved PA one year after and a significantly smaller 17% drop out. Their model and other Scandinavian models and more recently Ireland have emphasised the need for behavioural change science (psychology) to be a large component (Eynon et al., 2019). Where behavioural change science was emphasised and clients had high motivation; self-efficacy (Bandura,1986), Self-determination and, self-autonomy, this correlated to success in ERS (Markland & Tobin, 2010; Edmunds et al., 2007).

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