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Moving on up 01
Contents Acknowledgements 02
Foreword 03
1. Introduction 041.1 Anupdateontheevidence 041.2 Thepolicycontext 061.3 Exerciseandmentalhealthoutcomes 06
2. The GP survey - Four years on 102.1 Significantstatistics 102.2 Hasmuchchangedoverfouryears? 132.3 Exercise:nowanoption? 132.4 Summary 13
3. Site evaluations 143.1 Overview 143.2 Keyfindingsoftheevaluation 143.3 Runninganexercisescheme-lessonslearned 163.4 Theprojectsites 173.5 Analysisofsitedata 233.6 Exercisereferralschemes:dotheywork? 243.7 Keylearningpoints 28
4. Conclusion 30
5. Key recommendations 31
6. Appendices 33
7. References 44
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AcknowledgementsWewouldliketothankallthesiteswhotookpartinthisstudyandeveryparticipantwhogavetheirtimeandthoughts.WewouldespeciallyliketothankJacquiRyanandMatthewSaundersofFlitwickLeisureCentre;CarrieHolbrookoftheCambridgeStart-UpExerciseReferralSchemeandSiobhanRogers(andpreviouslyCaroleO’Beney)oftheCamdenActiveHealthTeam.
WewouldalsoliketoacknowledgethecontributionofChangingMindsinNorthampton,inparticularJayneShearsandSonyaTerry.
DrRowanMyron,DrCathyStreet,DanRobothamandKarenJamespreparedthisreportfortheMentalHealthFoundation.
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ForewordThisextremelyvaluablefollowupreportfromtheMentalHealthFoundationhighlightsanimportantsubject;thatifmentalhealthcontinuestoberegardedastheCinderellaservice,thenexercisereferralschemeswouldbetheuglysister.
Despiteaprovenandincreasingevidencebasetosupportsuchschemes,muchmoreneedstobedonetopersuadethoseinthehealthserviceoftheirbenefits.AlthoughthenumberofGPswhowouldprescribeexerciseasafirstlinetreatmentformildtomoderatedepressionisincreasing,itisdisappointingthatitremainsatlessthanfivepercent.Allhealthcareprofessionalshaveadutyofcaretopromoteexercise,thereforemuchmoreneedstobedonetoensurethatallwhoworkwithinprimarycarehaveaccesstoexercisereferralschemes.Thereshouldbenopostcodelottery.
Ourownexperienceasadeveloperanddelivererofexercisereferralprogrammesisthatactivity,beitphysicalorcreative,isanimportanttoolwhichshouldbeemployedtohelpindividualssufferingfrommildtomoderatedepression.
Theultimatetestamenttothesuccessofsuchschemesisthenumberswhoremainexercisingandphysicallyactivesincebeingreferred.ExercisereferralschemesmustcontinuetoevolveandflexibilityandvarietyarecrucialtosustaininginterestfromparticipantsandprovidingGPswithadecentpoolofschemestorecommend.Supportedactivityinitsbroadestsenseiswhatcounts,whetherthatisachievedwithinagymenvironmentoroutdoors.
Itishearteningtoreadmanyoftheencouragingcommentsfrompeoplewhoseliveshavebeentransformedbyexercise.Butwordofmouthalonefromthosewhohavecompletedsuchschemesisnotenoughandweapplaudandfullysupportcampaignssuchas‘UpandRunning?’intheirdrivetoraiseawareness.
RosiPrescottChiefExecutiveCentralYMCA
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1. Introduction
“TheextentofanyexerciseIdidbeforetheprogrammewasagentlewalk…nowIgotothegymand Ihavealsostartedtoattendalocalsportsgroup…”
Thereisasubstantialbodyofevidencetoshowthatphysicalexerciseisaneffectivetreatmentforpeoplewithmildtomoderatedepression.In2005MentalHealthFoundationpublishedthereport‘UpandRunning?’,whichhighlightedtheneedtopromoteexercisetherapyfordepressionasarealisticandreadilyavailabletoolforGPsandagenuineoptionthatpatientscouldbothunderstandandchooseforthemselves.
In2006,MentalHealthFoundationreceivedsomefundingfromtheDepartmentofHealthtosupportandevaluateasmallnumberofexercisereferralschemesacrossthecountry.
Thisreportinvestigatesthesuccessesandbarriersinplaceinsitescurrentlyrunningexercisereferralschemesandpresentsthekeyrecommendationsandlessonslearned.ThereportalsorevisitswhatGPscurrentlythinkaboutexercisereferralfouryearsonfromthefirstreport.
1.1 An update on the evidence
Primary Care
Previousstudieshaveindicatedthatphysicalactivityispositivelyrelatedtohealth-relatedqualityoflifeandwell-beingamongpeoplewithmild,moderateandseverementaldistress1.Althoughthephysicalhealthbenefitsofactivityarewelldocumented,evidencesuggeststhatphysicalactivityprovidesmanypsychologicalbenefitsaswell.Onestudy2exploredthepsychologicaleffectsofexerciseonliftingmood.Theinvestigatorsfoundthatpeopleexperiencingmentaldistressgenerallyhadalowlevelofphysicalactivity,theirhierarchicalanalysisoftwogroups(inSerbiaandAmerica)indicatedthatphysicalactivityremainedsignificantlypositivelyassociatedwithmood(evenafteraccountingforindividualvariationsinlevelofexercise).
Afurtherstudy3usedanevidencebasedapproachtodemonstratethatexerciseisnotjustphysicalactivityusedforthepurposeofconditioninganypartofthebody,buthaspositiveeffectsuponwiderphysicalhealth,mentalhealth,diseasepreventionandproductivity.
Intermsofexercisereferralprogrammes,onestudy4investigatedtheeffectivenessofatenweekprimarycareexercisereferralprogrammeonthephysicalself-perceptionandself-worthofolderadults.Theyfoundthatevenmoderatelevelsofattendanceimprovedself-perceptionandselfworth.
Whenlookingspecificallyatexerciseanddepressionasystematicreviewandmeta-analysisconcludedthatexercisemayreducedepressionsymptomsshortterm,butmuchoftheevidenceisinneedofreplicationandmorerobustresearch5.Anotherarticle,whichoverviewedthetreatmentofdepression,concludedthatphysicalactivitymayplayanimportantroleinrelievingdepression6
especiallywhencombinedwithothertreatments.
Intermsofanxietyandexerciseonestudy7foundthatphysicalactivitywasaneffectivetreatmentforanxietyhavingbeneficialeffectsonperceivedlifestresseventsandperceivedself-efficacy.
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Introduction
Anumberofdifferentstudieshavedemonstratedthepositivementalhealthbenefitsofexercisereferralwhilstexploringrecoveryfromaphysicalconditionsuchasstrokeorheartdisease.Oneveryrecentstudyin20098foundthatatenweekexercisereferralprogrammereduceddepressivesymptomsindepressedchronicstrokesurvivors.Theyfoundbothanimmediatepositiveeffect,andalsoalongertermeffectwhentheyfollowedthegroupup6monthslaterwithpatientswhohadparticipatedintheexercisereferralprogramme.Theynotedmodestimprovementsinhealthandwell-beingovertimeandtheyrecommendedthathealthprofessionalsshouldfocusonhelpingstrokesurvivor’smentalhealthrecoveryaswellastheirphysicalrehabilitation.
Secondary Care
Thusfar,theresearchevidencehasbeenfocusseduponexercisereferralinprimarycareformildtomoderateconditions.However,thereisnowanincreasingevidencebasethatexerciseandexercisereferralisappropriateandcanbeusedsuccessfullyinsecondarycaresettings,whetherininstitutionalisedsettingsorinthecommunityforthosewithsevereandenduringmentalhealthproblems.
OnestudywhichtookplaceinAustralia9notedthatintheAustralianhealthsystemthereisagrowingrecognitionandunderstandingoftheinextricableinterrelationshipbetweenphysicalandmentalhealth.Increasinglyinmentalhealthcaresettings,thephysicalhealthofserviceusersisacknowledgedasanissuerequiringurgentaction.Thisissue,theytheorise,isrelatedtonegativesymptomsandthelifestylechoicesofpeoplewithmentalillness.Theyalsonotethatthereisaclearlinkwiththedetrimentalsideeffectsofpsychotropicmedicationswhichcomplicatesthelackofconfidenceorskillinrelationtophysicalhealthmatters.Theauthorsnotethesignificantbenefitsofexerciseonmentalhealthandarguethatmentalhealthnursesandsupportingstaffmustplayanactiveroleinhealthpromotion,primarypreventionandtheearlydetectionandmanagementofphysicalhealthproblemsintheirmentallyunwellclients.
ArecentstudyinEngland10exploredtheuseofaprogrammeofexerciseandsportasasocialsupportformenwithseriousmentalillness.Thestudynotedthatsocialsupportwasimportantintheinitiationandmaintenanceofexerciseandfoundthatinformational,tangible,esteemandemotionalsupportwerebothprovidedforandgivenbyparticipantsthroughexerciseandnotedthatthiselementcouldbeasignificantsupportinanindividual’srecoveryjourney.
Exercisehasalsobeenshowntobeusefulwithininstitutionalisedsettings.Onestudy11investigatedtheimpactofaerobicexerciseontheseverityofsymptomsofPosttraumaticStressDisorder(PTSD)foradolescentsreceivinginpatientcare.Theyfoundthatafifteensessionaerobicexerciseprogrammehadapositiveimpactupontraumasymptoms,reducingsymptomologyandimprovingwellbeing.
Consequently,theresearchevidencebaseforexerciseasanappropriateandeffectivetreatmentformentalhealthisexpanding.
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1.2 The policy context
“Increasingexerciseisthemostcosteffectivewayofimprovingsomeone’shealth.Thereisasound evidencebaseofthebenefitstocardiovascularandpsychologicalhealth.”12
Overthelastdecade,thebenefitsofregularphysicalactivityhavebecomewidelyrecognisedinpreventingchronicdiseaseandpromotinghealthandwell-being,includingbeingendorsedforanumberofspecifichealthconditionsinNationalInstituteforHealthandClinicalExcellence(NIHCE)guidance13.
AreportproducedbytheDepartmentofHealthin200414,notedthatadultswhoarephysicallyactivehaveuptoa50%reducedriskofdevelopingchronicdiseasessuchascoronaryheartdisease,stroke,diabetesandsomecancers.
TheDepartmentofHealthpublishedareportin200515,examiningthebenefitsofphysicalactivityinreducingtherisksofdepression,reducinganxietyandenhancingmoodandself-esteem.Thereisnowagrowingevidencebasethatsupportstheuseofexercisetotacklemildtomoderatedepressionandanxiety.
1.3 Exercise and mental health outcomes
In2005,theMentalHealthFoundationpublishedthefindingsofitsstudyofexerciseasatreatmentoptionfordepression-‘UpandRunning?’16Thiswascommissionedtoexamineavailabletreatmentsformildandmoderatedepressioninprimarycareand,inparticular,tofocusonantidepressantandexercisereferralprescriptions,theiruseandavailability,andhowgeneralpractitionersandpatientsfeelaboutthem.
Thisreportnotesthefollowing:
“Thebenefitstophysicalhealth…ofregularexercisearewellunderstoodandaccepted.Butthebenefits tomentalhealth(reducedanxiety,decreaseddepression,enhancedmood,improvedcognitive functioningandself-worth)havebeenlesswidelyreportedandarelesswell-understoodandaccepted.”
Introduction
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Ithighlightstheconsiderablecostsassociatedwiththewritingofprescriptionsforanti-depressantsinEngland(£397.2millionin2003)andidentifiesthefollowingadvantages:
• Exercise is cost-effective–comparedtopharmacologicalandpsychologicalinterventions, evenstructuredexerciseprogrammescostlessoveranequivalenttimeperiod.
• Exercise is available–allexceptthoseinverypoorphysicalhealthcantakesome formofexercisewhichmakesitafarmoreavailableoptionthatmanypsychological treatments(highlightedbyavarietyofrecentreportsasbeinginshortsupplyandsubject tolongwaitingtimesontheNHS).
• There are co-incidental benefits-unliketheunpleasantsideeffectsthatcan accompanysomeantidepressantmedications,physicalactivityisrelativelylowrisk. Inaddition,exercisecanbeusedtotreatpatientswithamixofphysicalandmental healthproblems–forexample,itcanleadtohealthiermuscles,bonesandjoints alongsidepromotingasenseofachievementandincreasedself-esteemarisingthrough animprovementinphysicalappearance.(Alackofphysicalfitnessmayinitself beacontributingfactortoaperson’smentalhealthproblems).
• Exercise is a sustainable recovery choice–exerciserequirestheactiveparticipation oftheindividualwhichcanencourageandsupportpeople’sabilitytomakechoicesandwhich canbecontinuedwithoutongoingprofessionalsupervision.Thisisinsharpcontrast tosometreatmentswhichcanreinforcethesenseofbeinga‘passiverecipient’ofcare, whichcanreinforceoneofthecommoncharacteristicsofdepression,thatis,offeelingthat oneisunable,orhaslosttheabilitytomakechoices.
• Exercise promotes social inclusion and is a ‘normalising’ experience –exerciseiswidelyseenassomethingthatisdoneby‘healthy’peopleandassuch, carriesnostigma.Medicationand/orpsychotherapyontheotherhand,areoftendisliked becauseofthestigmaattachedtosuchtreatments.Thefactthatexercisecaneasilybe undertakenalongsideotherpeople,andcanprovideanavenueforsharedcommoninterests, providesanimportantsocialdimensiontotheactivity,whichcanhelptocounterthefeelings ofisolationsooftenexperiencedbypeoplewithdepressionandothermentalhealthproblems.
• Exercise is popular–althoughonlyfewqualitativestudieshavebeenundertaken, peoplewithdepressionarereportedtociteexerciseasbeinganimportant andpositivepartoftheirrecoveryprogramme.Forexample,inasurveyofpeoplewho hadexperiencedmentalhealthdifficultiesbyMindin2001,50%reportingfinding thatexercisehadhelpedthemtorecover.
Introduction
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The‘UpandRunning?’reportalsocitesaDepartmentofHealthfindingthatinanumberofcomparativestudies,physicalactivityhadbeenfoundtobeassuccessfulintreatingdepressionaspsychotherapyandthatintwoothers,ithadbeenfoundtobeassuccessfulintreatingdepressionasmedication.
PossiblepreventativeeffectshavealsobeenreportedinanumberofAmericanstudieswhichsuggestthatrisksofdevelopingdepressionarelowerforthosewhoengageinregularphysicalactivity.
Setagainstthesegenerallypositivefindingshowever,thereportalsohighlightssomeofthekeyfindingsfromsurveyoftwohundredGPswhichgoessomewaytoexplainingwhyexerciseisstillnotoftenthoughtofa‘treatmentoffirstchoice’.Theseinclude:
• Pressure to act–toalleviatethedistressapatientmaybefeeling,GPscanfeelpressuredinto offeringimmediatereliefintheformofmedication(especiallyifthisisrequestedbythepatient).
• Time poverty–thesurveyresultsindicatethatdrugprescriptionratesincreasewith thenumbersofpatientsontheGP’slistwhichmaysuggestthatthoseGPswhoaremore time-pressuredarealsomorelikelytoprescribeanti-depressants.
• Limited alternatives–difficultiesaccessingpsychotherapyorcounsellingprovision (whichcanalsobeexpensive)canresultinGPsoptingfortheimmediatelyavailable optionofprescribinganti-depressants.
• Limited visibility of non-pharmacological and non-psychotherapeutic alternatives –incomparisontothewell-publicisedtrialsofantidepressants,whicharelargelyfundedby thepharmaceuticalindustry,muchlowerlevelsoffundinghavebeenavailableforresearchinto theoutcomesofalternativessuchasexercise;thefindingsoftheresearchthathasbeencarried outalsomaynotreachGPsandotherhealthcaredecision-makers.
• Expediency–findingsfromthe‘UpandRunning?’studysuggestedthatdoctorsareaware ofthestrongplaceboresponseanantidepressantmayproduceandthat,giventhe limitedavailabilityofpreferredalternatives,mayprescribeantidepressantsasanexpedient inthehopeofinducingsucharesponse.
• The dominance of pharmacology–medicationhasbeenthefavouredresponse inprimarycareforsomeconsiderableperiodoftime,aresponsethathasbeenreinforced byextensivepowerfulmarketingbythepharmaceuticalindustry.
Introduction
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Crucially,thereportgoesontonotethatmanyGPsareuncomfortablewiththewaymildormoderatedepressionismanagedinprimarycare,theywouldlikemoreaccesstoalternativetreatmentoptionsandthat,iftheyhadsuchaccess,theirprescribingbehaviourwouldaltersignificantly.
Itsuggeststhatanimportantwayforwardmayliewithexercisetherapywhich,throughdeliveryinanappropriatelysupervisedcontext,couldmakeasignificantdifferencetomanypeoplepresentinginprimarycarewithmildormoderatedepressionby:
• Expanding patient choice and power over their recovery–“depressionisaconditionthat thrivesonperceptionsofpowerlessness,andassuch,anexpansionofchoiceandpowermayitselfhave therapeuticeffects.”
• Helpingpeopletoeffectasustainablelifestylechangethatmaycontinuetosupporttheir mentalandphysicalhealthinthelong-term.
OtheradvantagesincludeempoweringGPsbyprovidingthemwithgreaterscopetoofferholistictreatmentplansand,ultimately,awideruseofexercisetherapycould:
“reducethecostburdenontheNHSprescriptionbudget,bygivingGPsgreaterfreedomtoexplore non-pharmacologicalapproachestotreatment,anddiscouragingpatientswithmildtomoderate depressionfromlong-termdependenceonmedication.”
Introduction
2. The GP survey – Four years on
AspartofthefirstreporttheMentalHealthFoundationsurveyedGPsinNovember2004toexploretheirperceptionsofexercisereferralasaprescription.ThissurveywasrepeatedinNovember2007toexaminewhethertheratesandacceptanceofGPreferraltoexercisehadchangedintheinterveningyears.Anationallyrepresentative,quotacontrolledgroupoftwohundredNHSGPsweresurveyed.ThemajorityofGPssurveyedwerefromEngland,atenthofGPswerefromScotlandandjustunderatenthwerefromWales,3%werefromNorthernIreland.
GPswereaskedabouttheirtreatmentresponsesforpatientswithmildtomoderatedepression.JustunderhalfofGPssaidthattheyprescribeantidepressantmedicationastheirfirsttreatmentresponseandthemajorityofGPsbelievethistobeeffective.Incontrast,thoughoverhalfoftheGPssurveyedbelievedexercisetobeaneffectivetreatment,only4%saidtheywouldrefertoasupervisedprogrammeofexercise.Interestingly,whenaskedabouttheirchoiceoftreatmentforthemselvesiftheybecamedepressed38%ofGPswoulduseantidepressantmedicationastheirfirstchoiceofself-treatmentand18%woulduseasupervisedprogrammeofexercise.
Whenconsideringtalkingtherapytreatments,overathirdofGPswouldreferpatientstosomeformofcounsellingorpsychotherapyastheirfirsttreatmentresponseand10%ofGPswouldrefertheirpatienttocognitivebehaviouraltherapy.
WhenaskedabouttheirthreemostcommontreatmentresponsesforpatientswithmildtomoderatedepressionalmostallGPs(94%)wouldprescribeanti-depressantmedication,thisisinlinewiththefindingsfromthe2004survey(92%).However,21%ofGPssaidtheywouldrefertoasupervisedprogrammeofexerciseand4%woulduseitastheirfirsttreatmentresponse,thisisoverfourtimesmorethantheresponsein2004survey.
Significantly,over40%ofGPsdonothaveaccesstoanexercisereferralscheme.Ofthese,95%saidthattheywouldreferpatientswithmildtomoderatedepressiontoanexercisescheme,iftheyhadaccess.OftheGPswhodidhaveanexercisereferralschemeover80%useditasatreatmentfortheirpatients.
2.1 Statistics
• 45%ofGPsmostcommonlyprescribeantidepressantsastheirfirsttreatmentresponse tomildormoderatedepression.36%ofGPsmostcommonlyrefertosomeform ofcounsellingorpsychotherapyastheirfirsttreatmentresponsetomildormoderatedepression, 10%ofGPsrefertocognitivebehaviouraltherapyastheirfirsttreatmentresponse. 4%ofGPsmostcommonlyrefertoasupervisedprogrammeofexerciseastheirfirsttreatment responsetomildormoderatedepression(Figure2).
• 72%ofGPsbelievethatantidepressantsare‘quiteeffective’,19%believethemtobe ‘veryeffective’.56%ofallGPssurveyedbelievethatasupervisedprogrammeofexercise is‘quiteeffective’inthetreatmentofmildtomoderatedepression,5%believethat itis‘veryeffective’(Figure1).
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Figure 1: GP perceptions of the effectiveness of exercise and antidepressants for patients with mild or moderate depression
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• Whenaskedabouttheirthreemostcommontreatmentresponsesformild tomoderatedepression94%ofGPsprescribeantidepressantmedication,21%ofGPsrefer toasupervisedprogrammeofexercise(Figure2).
Figure 2: GP preferred choices of treatment for patients with mild or moderate depression
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• 38%ofGPsstatedthatiftheybecamedepressedtheywoulduseantidepressantsastheirfirst choiceoftreatment,18%ofGPswoulduseasupervisedprogrammeofexerciseastheirfirst choiceoftreatment.83%ofGPssaidtheywoulduseantidepressantmedicationasoneoftheir topthreetreatmentsforthemselves,43%ofGPssaidtheywoulduseexercise(Figure3).
Figure 3: The treatment strategies that GPs would use if they themselves became depressed
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• 42%ofGPssurveyeddonothaveaccesstoanexercisereferralscheme.
• OftheGPswhodidhaveaccesstoanexercisereferralscheme3%referredtheirpatientstoit ‘veryfrequently’,22%‘fairlyfrequently’,61%‘notveryfrequently’and14%didnotuseitatall.
• 95%ofGPswhodidnothaveaccesstoanexercisereferralschemesaidthatiftheydidthey woulduseitasatreatmentformildtomoderatedepression,15%saidtheywoulduseit ‘veryfrequently’,51%saidtheywoulduseit‘fairlyfrequently’and29%‘notveryfrequently’.
• 70%ofGPssaidthattheywouldusemoresocialprescribing(forexample; bibliotherapy,exercisereferral,self-helpgroupreferral)forcommonmentalhealth problemsiftheyhadtheoption.
• 16%ofGPssaidthatoverthepasttwoyearstheyhadnoticedanincreaseinthenumber ofpatientswithmildormoderatedepressionaskingwhetherexercisewouldbeasuitable treatmentfortheirmentalhealthproblem.
TheGPsurvey-Fouryearson
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2.2 Has much changed over the last four years?
AntidepressantprescriptionisstillthemostfavouredresponsebyGPswith55%choosingthismethodastheirfirstresponsein2004and45%in2007.Someformofpsychotherapyorcounsellingwaschosenby32%ofGPsastheirfirstresponsein2004,and36%in2007.Lessthan1%ofGPsin2004wouldrefertoasupervisedprogrammeofexerciseastheirfirstresponse,by2007thisfigurehadrisento4%.In2004,41%ofGPsbelievedexercisetobe‘quite’or‘very’effectiveasatreatmentby2007,thisfigurehadrisento61%.
Iftheybecamedepressedthemselves,moreGPsnowthanin2004,wouldtryexercisethemselves.In200440%wouldtrycounselling/psychotherapyfirst,38%wouldtryantidepressantsfirstand11%wouldtryexercisefirst.In2007,38%wouldtryantidepressantsfirst,27%wouldtrycounselling/psychotherapyfirstand18%wouldtryexercisefirst.
2.3 Exercise: now an option?
Intermsofavailabilityofanexercisereferralscheme,thepicturereportedbyGPshasn’tchangedconsiderably.42%ofGPsreportedaccesstoaschemein2004,in2007thisfigurehadrisento49%,stilllessthanhalfofGPssurveyed.25%ofthoseGPswhodohaveaccesswouldrefer‘fairly’or‘very’frequently.Thisisariseoverthefigurereportedin2004of15%.
GPswereaskediftheyhadnoticedanincreaseoverthelasttwoyearsinthenumberofpatientsaskingwhetherexercisewouldbeasuitabletreatmentfortheirmildtomoderatedepression.16%hadnoticedanincrease,80%hadnot.Whenaskediftheywoulddomoresocialprescribing70%ofGPssaidtheywouldliketorefermoreofteniftheyhadtheoption.
2.4 Summary
TheGPssurveyedseemedremarkablyopentotheoptionofexercisereferralandbelieveinitseffectivenessandusehasrisenoverthelastfouryears.MoreGPsinthecurrentsurveythanin2004wouldrefertoasupervisedexercisereferralscheme.Furthermore,manyGPswouldliketohavetheoptiontorefertosuchschemes.Similarlytothepicturerevealedinthepastsurvey,GPsarestillmorelikelytoprescribeantidepressantsthanexercisereferralortalkingtherapies.
GPsweremorelikelytouseexerciseschemesiftheythemselvesbecameill.However,eveninthiscase,GPsaremorelikelytoprescribemedicationastheirfirstchoiceoftreatment.
TheGPsurvey-Fouryearson
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3. Site evaluations
“Makesmefitter,givesmemyownspace,feelgoodafteritandfeellikeIcancopewitheverything…”
(Interviewee,exerciseschemeparticipant)
3.1 Overview
ThissectiondescribesthefindingsoftheevaluationofaselectednumberofexercisereferralschemeswhoparticipatedintheprojectsupportedbytheMentalHealthFoundationwithfundingfromaDepartmentofHealthgrant.
Thecentralfocusofthisevaluationhasbeenondevelopinganin-depthunderstandingoftheexperiencesofindividualsreferredtotheexerciseschemes,thelastingimpactoftheirinvolvementinexerciseactivitiesandtheirperceptionsofanychangeintheirphysicalandmentalwellbeingasaresultoftakingpartinanexerciseprogramme.
QuantitativedataincludedbaselineinformationalreadyroutinelycollectedbythepilotsitesandalsothedistributionoftheRecoveryEvaluationForm(seeAppendixA).Qualitativeinformationwasgatheredfromfocusgroupsandindividualinterviewswithserviceusersandstafffrom2selectedleisure/exercisesettings.Thequalitativedatafromtheotherpilotsitesisoutlinedalongsidethecollationofotherrelevantfeedbackgatheredfromexerciseparticipantsinthesesites.
NationalResearchEthicsCommitteeApprovalforthestudywasgivenbytheRoyalFreeMedicalSchoolResearchEthicsCommitteeinApril2008andtheinformationgatheringcommencedthatmonthandranthroughoutthesummeruntiltheendofSeptember.
3.2 Key findings of the evaluation
Thefindingsfromtheevaluationhighlightarangeofbenefitsforthosetakingpartinexercisereferralschemesandalsothatthereareanumberoffactorstobeborneinmindinsuccessfullydevelopinganddeliveringexercisereferralprogrammes.
Withregardtothebenefitsforthosetakingpart,thefollowingwereidentified:
Physical and psychological benefits:
Nearlyalloftheparticipantsintheevaluationdescribedfeelingphysicallyandpsychologicallybetterasaresultoftakingpartinaprogrammeofexercise,withmanycommentsaboutincreasedconfidence,feelingmoreenergeticandgenerallyfitter.
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Thequotesbelowillustratethecorethemefindings:
“Therehavebeenmanybenefitstomeinattendingthisprogramme.Oversixweeks, Ihavelostweightandmybloodpressureisnowwithinthe‘normal’range…Mymoodhaslifted… Ihadbeenfeelingverylowbeforeattendingthisprogrammeandusingthegymhasdefinitely hadapositiveeffectonmymood…”
And:
“myinstructorhascontributedtothequalityofmylifegreatly –fromcuringanachinghiptocuringtheblues”
Tackling isolation, promoting social inclusion and supporting peer relationships:
Manyofthosewhowereinterviewedlivedaloneandwerequiteisolated;severalhadexperiencedbereavementinrecentyears(apossiblecausalfactorofdepression).
Inthefocusgroupsandindividualinterviews,thesocialbenefits(andthemotivationaleffects)ofjoininganexerciseprogramme,wasaprominenttheme:
“Isufferfromdepressionandhavefoundthattheexerciseclassesreallyhelpedtoimprove mymood.Myphysicalfitnesshasalsoimproved.InthepastIhavebelongedtogyms buthavealwaysstoppedgoingafterawhilebecauseitwashardtomotivatemyself.Ifindgoing toagroupactivityveryenjoyable.Youseethesamepeopleeveryweekandgraduallyget toknowoneanother.Knowingyouaregoingtoseefriendsmakesexerciselessofachoreandmore ofapleasantsocialactivity.Overall,theexerciseclasseshavehelpedmetogetfitter andtoavoidarelapseintoseveredepression.”
Anothermadethefollowingstatement:
“IamnotexaggeratingwhenIsaythatittransformedmylife.IhavetakenpartinactivitiesthatIhad neverdreamedofbeforetheschemeandhavemadenewfriends”
Tackling anxiety and promoting confidence:
Severaloftheintervieweesreportedhowattendanceatanexerciseclasshadhelpedthemtoovercometheirfeelingsofanxietyandfearofleavingtheirhomestogointosocialsituationswithotherpeople.Theydescribedhowwiththeencouragementofsupportiveexerciseinstructors,alongsideasenseofwhatonedescribedasthe“physicalexhilaration”aftercompletingaclass,theyfeltlessanxious:
“IdoknowthatifbeforeasessionIamanxiousorfearful,duringtheworkoutthesefeelings diminishandafterwardsInoticethatIfeelrelaxed,feelIhaveachievedsomethingandthatmy sleepingthatnightisbetter.”
Siteevaluations
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Improved cognitive functioning:
Awidelyreportedimprovementwaspeople’sabilitytoconcentrate,toplanandtocompletetasks.Thereweremanycommentsaboutthewayattendinganexerciseclassgavestructuretotheday,andaboutlookingforwardtotheactivitiesandachievingthegoalssetbytheexerciseinstructors:
“Ithashelpedmetofocusandtoplan.Iamalsostartingtothinkabout newthingsImighttryinthefuture.”
3.3 Running an exercise scheme – lessons learned
Intermsofthedevelopmentofexercisereferralschemes,theevaluationrevealedthatvariousfactorsarecurrentlyimpactingonthesuccessfuldevelopmentoftheschemesincludingfundingconstraintswithinlocalgovernmentand/orprimarycaretrusts.Inaddition,thefindingshighlighttheimportanceofthefollowing:
• Itappearsthatthereisstillquitelimitedawarenessofexercisereferralschemesamongst manywhomightrefer–savefortheoccasional‘champion’GPorpracticenurse –andthatongoingandhigherlevelactivitytopromotethebenefitsofexercisetherapy areneeded,includingadvertisingthroughawiderrangeofvenuessuchaslibraries, furthereducationcollegesandjobcentres.
• Referrerstoexerciseschemesneedtounderstandwhatisonoffersothattheycanpick the“righttimeandtherightactivity”tosuggestaschemetotheirpatients–ifexercise referralschemesarejustroutinelymentionedasapartofahealthconsultation, variousintervieweessuggestedthatpeopleareunlikelytohavetheconfidencetorespond.
• Thereferralprocessitselfisanimportantavenuetoclarifypatients’expectationsandworries aboutanexerciseactivity,whichcaninturncontributetoachangeinattitudesandbeliefsabout exercise.ThisisalsonotedintheearlierevaluationoftheCamdenscheme(oneofthepilot sitesinthisstudy)byMiddlesexUniversitywhereitisconcludedthat:
“Providingpatientswithinformationrelatingtotheactivitiesonoffer,thevenues,andtheclasstimes, enablesthemtoselectanappropriateexerciseclassthatsuitstheirrequirements.Givingpatientsthe freedomofchoiceislikelytofacilitatebehaviourchange…”17
• Individualisedsupporttoengagepeopleinthefirstclassofanexerciseprogramme isessentialiftheyaretoattendpasttheinitialsession.Intwoofthepilotsites,quitehighdrop outratesofpeoplereferredformentalhealthreasonswerereportedanditwassuggested thatalackofconfidenceandfearofnewsocialsituationsweresignificantdeterrents totheirsuccessfulengagementintheprogrammes.
• Itisimportanttohaveamenuofexercisechoicesavailable–notjustgym-basedprogrammes sinceforsomepeoplewithmentalhealthproblems,lessstructuredandmoreopen-ended activitiessuchashealthywalkingschemes,maybemoreappropriate.Ifpossible, ‘taster’sessionsshouldbeofferedtoeasetherouteofaccess.Familiarstaffmembers, whofollowthroughonvariousdifferentactivities,canhelptoencouragepeopletotrynew things.Inaddition,providingaccesspointsintootheractivities,oncetheinitialprogramme ofexerciseiscomplete,iskeytokeepingpeopleactiveandsupportingtheirrecovery.
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• Offeringprogrammesatdifferenttimesoftheday,includingintheearly evening,isrecommendedtotakeaccountofthedifferentcommitments ofthosereferred.Somepeoplemaybein,oroncetheystarttofeelbetterwill bereturningto,employmentsothisshouldbefacilitatedviaflexibletimings.
• Venuesneedtobeaccessiblewithhighqualityandwell-maintained facilities.Variousrespondentstalkedoffeelingputoffbypoorlymaintained andover-crowdedexercisevenues.
• Respondentsintheevaluationemphasisedthatthepaceofexerciseactivityneedstobe tailoredtomeettheneedsoftheindividualsreferred,especiallysincemanypatientswithmental healthneedsmayneverhavetakenpartinastructuredprogrammeofexercisebefore.
• Thesizeofthegrouporexerciseclassisimportant–toosmallandtheopportunitytomake newfriendsandformsocialnetworksislost(orgroupsruntheriskofbeing‘cliquey’), whilstontheotherhand,ifthegroupistoolargethiscanseemdauntingandimpersonal.
• Costisakeyconsiderationformany,withanumberhighlightingthat theavailabilityofdiscountschemesorloyaltycardshadinfluencedtheirdecision tocontinuewithanexerciseactivityoncetheinitialprogrammewascomplete.
3.4 The project sites
“Forpeoplewithforexamplementalhealthproblems,itgivesyoutheencouragementyouneedtoget thetrainersinthebagandgoknowingthattherewillbesomeonetheresupportingyouandotherslike youinthesameboat.It’sbeenanewexperienceformeandapositiveone…”
(Exerciseschemeparticipant)
Fivepilotsiteswereoriginallyselectedforinclusionintheevaluation.Thesewere:Bedfordshire;Camden;Northamptonshire;CambridgeandWirral.Asixth,RedcarandClevelandwaslateraddedtothegroup.
Duetothesmallsizeofsomeoftheexercisereferralschemesintheseareas,andbecauseoneoftheschemeswasonholdwithbudgetaryconstraints,astheevaluationprogressed,thedecisionwastakentofocusonthethreeschemesthatwerefullyoperationalandwereofasufficientsizetogatherquantitativedata.ThesewereBedfordshire(Flitwick),CamdenandCambridge.Overviewsofthesethreeschemes,plusbriefdescriptionsoftheotherthreepilotsitesfollow:
Bedfordshire exercise referral scheme at Flitwick Leisure Centre
Bedfordshirehasbeenrunninganexercisescheme“ActivitiesforHealth”forapproximatelyfouryears,withtheschemeacceptingpatientsfromfourlocalGPpracticesforavarietyofphysicalhealthproblems,notablycardiacproblemsandobesity.TheschemeoperatesoutofthreelocalsiteswiththeFlitwickbasebeingthelongestestablished.
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Alsointhecounty,thelocalPrimaryCareTrust(PCT)supportsavarietyofactivityreferralschemesinBedforditself:therearevariousestablishedhealthywalksschemesandinLutonandDunstableandawell-establishedexercisereferralschemeforcardiacpatients.
InMarch2007,theFlitwickcentrebeganapilotprojectforexercisereferralwithpatientsexperiencingcommonmentalhealthdisordersfromoneoftheGPpracticesaspartoftheNationalPrimaryCareMentalHealthCollaborative.Thescheme,whichdevelopedinresponsetotheevidentmentalhealthneedsamongstthosereferredforprimarilyphysicalhealthreasons,isforpeoplewhoareexperiencingmildtomoderatedepressionandoranxiety.Priortoreferral,patientsareassessedinprimarycareusingtheHospitalAnxietyandDepressionScale(HAD)and,oninduction,afitnesstestisundertakenwhichhelpstoinformtheprogrammeofexercisethatisrecommended.
AlllevelsoffitnessareacceptedatFlitwick,whichoffersarollingprogrammeofgym-basedactivitiesalongwithotheractivitiessuchashealthywalksthatarerunwhentheweatherisappropriate.Pilates,circuitsandaquaaerobicsarealsoavailable.PCTfundingcoveredsometraininginmentalhealthforthetwoleadmembersoftheexercisestaff,who,inadditiontorunningtheactivities,haveplayedakeyroleindisseminatinginformationaboutthepilotprojecttolocalGPpractices.
Thecentrepromotessocialinteractionsbetweenclientsattendingtheexercisegroupsbyprovidingfreerefreshmentsafterthesessionsandoftengroupmemberswillmeettogetherforlunchorasnackintheleisurecentreaftertheirclass.Thecostis£2.50persession,withaconcessionaryrateof£1.25forthosethatarenotinemployment.
Duringtheevaluation,referralstotheexerciseschemecontinuedtobepredominantlyforcardiacandweightlossreasons,withveryfewreferralsformentalhealthissues.Analysisofthereasonsforstoppingattendancesuggestedthatsomepeoplefoundthegym-basedcoursetoostrenuousandtwowereadvisedbytheirGPtostopduetoillness.Inanattempttoencouragemorereferralsofmentalhealthclients,planstoenlistmoreGPpracticeswereagreedin2008;however,amajorissueinfluencingtheseplans,andalsothecurrentrateofreferrals,wasacknowledgedtobeuncertaintyaboutplanstore-developanewleisurecentreonasitemoreinthetowncentre.
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CASE STUDY A
Jamesheardabouthislocalexercisereferralschemethroughthelibraryand,feelingveryunhappyandisolatedasaresultofhisweight,askedhisGPforareferral.Severalweekslater,hemetamemberoftheCountyCouncilfundedexerciseteamwhoplannedwithhimagym-basedprogrammeofclasses.
Jamesdescribedattendingagymforthefirsttimeasverydauntingsinceheisalsopronetopanicattacksinneworunfamiliarsituations.However,becausehewassupportedthroughouttheprogrammebytheexerciseteammemberofstaffwhohadfirstassessedhim,andbecausehejoinedasmallgroupofpeoplewithsimilarproblems,hemanagedtocompletethefirstclassandthenstartedattendingclassesonceaweek.
Astimepassed,Jamesnoticedthathewasgrowinginconfidencetotrynewpiecesofequipmentandthathisstaminawasimproving.Healsoreportedmoresettledsleepandsomeweightloss.Byconcentratingonbreakingthesmallrecordshehadsetforhimself,hefoundthatanyanxietieshehadonthewaytotheclassdidnotescalateintoapanicattackandveryoften,justdisappeared.
Oncompletionoftheeightweekinitialprogramme,Jamesdecidedtojointhegymonapermanentbasis.Heincreasedhisattendancetotwiceweeklyandalsojoinedalocalteamsportsgrouprunbytheexerciseteam.
Camden Exercise Referral Scheme
TheCamdenExercisereferralSchemewasestablishedin2004andhasateamofspecialists–theCamdenActiveHealthTeam–forspecificconditionsanddisorders.Theydelivertheexercisetothosereferredintothescheme.Theschemeisopentopeopleagedeighteenandoverwhohaveoneormoreofthefollowingchronichealthconditions–obesity,diabetes,osteoporosis,coronaryheartdisease,cardiovasculardisease,andchronicobstructivepulmonarydisease.Peoplewithmentalillnesses(neuroticandpsychoticdisorders)andpeopleagedsixtyorolder,whoaresedentaryandatriskoflosingtheirindependence,arealsoeligible.
TheActiveHealthTeam,whoseexerciseleadersareallqualifiedtolevel3ontheRegisterofExerciseProfessionals,acceptsreferralsfromarangeoflocalhealthprofessionalsincludingGPs,practicenurses,physiotherapists,mentalhealthnursesandoccupationaltherapists.Onceareferralhasbeenmade,theindividualwillhavetheirfirstconsultationwithintwoweeksand,atthistime,theteamusethevalidatedoutcomesmonitoringtoolsSF-12andIPACtolookathealthandthelevelofexercise.Thesescalesarecompletedagainattheendofanysessions.Theteamalsorequestinformationaboutanymedicationsapersonmaybeonandanyexerciseimplicationsarisingfromtheircondition.
TheexerciseschemeinCamdenprovidesactivitiessuchasgreengym,sportsgroups,yogaandPilatesandthosereferredtotheschemereceiveaneightweekprogrammefreeofcharge.Thoseconsideredtobeatriskoflosingtheirindependencebecauseofahealthconditionthatlimitstheirabilitytoleavetheirhouse,areofferedone-to-onesessionsintheirhome.Afterthefirstprogramme,participantscanthenchoosetocontinuewithanyclassesoractivitiesthattheyaredoingforthecostof£1.00asessionortojoinalocalgymforaround£16.00amonth.
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AllGPsaresentfeedbackaftertheeightweekprogrammeandthereisfollow-upatninemonths.OperationoftheCamdenschemeduringitsfirstfourteenmonthswasevaluatedbyMiddlesexUniversity,withtheresultsshowing:
• Highratesofcompletionoftheinitialexerciseprogramme.
• Manypatientsreportingimprovedmentalhealthasaresultofparticipation inthescheme,includingincreasedlevelofpositivemood.
• Thatwhilstthereferralswerelimited,referrerstotheschemehadreceived positivefeedbackabouttheschemefromtheirclients.
Thefindingsalsohighlighttheimportanceofusingeasilyaccessiblevenues,withmanyoftheparticipantsexperiencingnegativejourneysonpublictransporttoattendtheexerciseclasses,andfurtherhighlighttheimportanceofhavingfacilitiesthatarelargeenoughandinagoodcondition.Finally,theroleoftheexerciseleaderinsupportingengagementisapparent:
“Patientsstatedthatthefactthattheyhadmetthementalhealthco-ordinatorattheirinitial consultation,andthatthissameco-ordinatorwouldbeinstructingtheclass,madethemfeelmore comfortableaboutattending.Movingintoadifficultclasswheretheydidnotknowanybody wasperceivedas‘difficult’and‘daunting’.”18
CASE STUDY B
Annawasreferredtoherlocalexerciseschemefollowingseveralmonthsoftreatmentfordepressionandanxiety.Shewasinterestedinattendingagroup-basedactivitybecause,althoughshehadajob,thiswasinatownsomemilesawayandshefeltisolatedinherlocalareaandhopedtomeetsomenewpeoplethroughthegroup.
Workingmeantthatsheneededtobeabletoattendtheexerciseactivityintheeveningsbutalsothatshewasquitetired.Havingstartedonagym-basedcourse,shefoundthistoostrenuousandnotaneasywaytogettoknowotherpeoplesochangedtoanaquaaerobicsclasswhichshefoundmorefun.Intime,shealsobegantotakepartinsomeofthehealthywalkswhichwereavailableattheweekend.
Annareportedenjoyingtheactivitiesonofferandthatthemainbenefittoherhasbeenhavingareasonto“getoutandaboutratherthanjustwatchingthetelevisiononmyown”.Shehascontinuedtoexercisehavingcompletedtheinitialprogrammeshewasreferredto.
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Cambridge Exercise Referral Scheme
InCambridge,theexercisereferralschemeiswellestablishedandhasbeenrunningforovertenyears.Therearetwophysicalactivityschemes,whicharerunbyCambridgeCityCouncil’ssportsdevelopmentdepartmentthathaveamentalhealthcomponenttotheirwork,Start-UpandInvigorate.Bothprojectsofferarangeofactivities;however,amajordifferenceisthatInvigorateoperatesmoreatthesecondarylevelandisfocusedonsupportingpeoplewithestablishedmentalhealthproblems,whereasStart-Upisaimedmoreatthosepeoplewithmildandemergingmentalhealthproblems.Forthisreason,onlytheStart-Upschemewasincludedinthisevaluation.
Start-UpisamemberoftheCountyPhysicalActivityandHealthGroupwhichhasrepresentativesfromawiderangeoflocalorganisationsincludingtheNHSCambridgeshire(formerlyCambridgeshirePCT)andlocalauthorities.Whentheschemeoriginallybegan,onlyGPswereabletorefer;however,theintroductionoftheNationalQualityAssuranceFrameworkforExerciseReferralSystemsin2001providedguidanceonalliedhealthprofessionalswhocouldalsoreferandthishasledtoreferralsbeingacceptedfromnurses,physiotherapists,occupationaltherapistsanddieticians.TheStart-Upschemerunspredominantlyfromtwomainleisuresettingswithinthecityandalsoseveralcommunitycentres.
StaffedbyLevel3ExerciseProfessionals,whoundertaketheinitialassessmentandplanningofanindividualtwelveweekexerciseprogramme(includingidentificationofthemostsuitablelocationforapersontouse),theStart-Upschemeoffersavarietyofactivitiesincluding:supervisedgym,swimming,aquamobility,specialistcircuitbasedclasses,exercisetomusic,Pilatesandchair-basedexercise.Thesesessionsareonlyavailabletocurrentorpastexercisereferralclients,andapartfromthosewishingtoengageinahomebasedprogrammetherearenofreeactivitiesprovided.However,viathelocalLeisureCardschemeandthroughnegotiatedservicelevelagreementsamongstprivateproviders,avarietyofdiscountsapply.
AnalysisoftheuptakeoftheStart-Upprogrammesuggeststhattherearearoundthirty-twonewreferralseachmonth,withthethreemostcommonreasonsforreferralbeingmusculoskeletal(includingbackpainandarthritis),obesityanddiabetes.Mentalhealthisaroundthe5-6thmostcommonreason.60%ofthosereferredcompletetheinitialtwelveweekprogramme,manyofthosewhodocompleteaprogrammethencontinuewiththeirchosenactivityorhaverevitalisedconfidencetoengageinsomeotherchoice.OnepopularrouteforthosewhoarereferredformentalhealthreasonsistothenjoinasamemberoftheInvigorateproject.Membershipisfreeand,althoughnoindividualisedandtailoredsupportisoffered(unliketheStart-Upscheme),Invigorateprovidesanarrayofgroup-basedactivity,canbemoreflexibletotheclient,providesawiderchoiceofsportsandischeaperforclientstoattendonalonger-termbasis.
Commonreasonsgivenfornon-completioninclude‘lackoftime’and‘notenjoying’theactivity–againemphasisingtheimportanceofofferingachoiceofexerciseoptions.
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CASE STUDY C
Followingthedeathofherhusband,Marionbecameincreasinglyisolatedandwithdrawn.Shehadgivenupherjobandwasspendingalotofhertimeasleeporwatchingthetelevision.Shewasreferredtoherlocalexerciseschemewithadiagnosisofdepressionandfollowinganassessmentbytheexerciseco-ordinator,agreedtotryayogacourse.
Marionwasveryfearfulofattendingthefirstyogaclasssinceitwasmanyyearssinceshehaddoneanyexerciseofanytype.However,herworriesrecededwhenshediscoveredthatsheknewseveralofthegroupmemberswhowerealsoinvolvedinsomeother‘lowkey’exerciseactivitiessuchasadancingclass.Theyogagroupwasalsoverysociable,oftengoingforcoffeetogetherafterclass.
Intime,Mariondescribedfeelingmuchmorephysicallyalertandactive.Byhavingsomethingtolookforwardtowhichsheenjoyed,shewasalsolesspreoccupiedwiththoughtsofherhusband.Shebegantothinkaboutreturningtoworkandasafirststeptowardsthis,decidedtovolunteerinherlocalcharityshop.
Northampton, Redcar and Cleveland and Wirral exercise referral scheme
InNorthampton,theexercisereferralschemeisbasedarounda12weekprogrammeofgymbasedactivities,with24GPpracticesbeingaffiliatedtothescheme.Commonmentalhealthproblemsarethesecondhighestreasonforreferral(17%ofreferrals)behindreferralsforobesity(25%).
Theschemeoperatesoutofanumberofdifferentsitesinthecountyandscreening/assessmentattheinitialconsultationiskepttoaminimum.Afteraninitialtwoweekperiodofactivitiesthatarefreeofcharge,pricesarechargedandvarydependingonthelocationandexerciseactivityselected.Allthosereferredforexercisearealsogivenaleisurecardthatentitlesthemtodiscountsonotherfacilities,backedbyadviceandinformationastotherangeofsportingactivitiesavailable.Thereissomeflexibilityintheschemeandpeoplecansometimesbereferredforasecondtimeattheendofthefirstprogramme.
Redcar and Cleveland’shealthywalksschemehasbeenrunningforoverfiveyearsandhasaroundonehundredpeopleonitsregisterandaregularweeklyattendanceofbetweenthirtytofortypeople.Reasonsforreferralvarybutweightproblemsareprominent.Theschemeaimstobeasflexibleaspossibletokeeppaperworktoaminimumand,assuch,onlylimitedhealthinformationiscollectedwhenpeoplejointhescheme.InformationabouttheprogrammeofwalksisdisseminatedonaregularbasisviaalllocalGPspractices,practicenursesandlocalhealthcentres.
Wirraloffersasimilargym-basedschemetotheBedfordprogrammedescribedearlier.ReferralscurrentlycomefromoneGPpractice.
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CASE STUDY D
Samsawhislocalexercisereferralschemeadvertisedinhislocalhealthcentre.Hehadahistoryofdepressionarisingfromatraumaticworkinjurysustainedsomefiveyearspreviouslywhichhadlefthimwithconstantbackpain.Afteraninitialconsultationwiththelocalsportsteam,Samdecidedtotryoneofthesupervisedswimmingexerciseclasses.
Samfoundthattheclassgavehimsomethingtolookforwardtoand,bygraduallyswimmingforlonger,thathisgeneralfitnessimproved.Althoughitdidnotcompletelycurehisbackpain,hereportedfeelingthathisposturehadimproved.Healsofeltless‘low’andpositiveabouthisachievementsintheclass.
Samemphasisedtheneedforwideradvertisingofexercisereferralschemes,pointingoutthatitwasonlybecausehewasalreadyinpainandinneedofhelpfromhisdoctorthathewasinthehealthcentreandthatthisis“missingoutlotsofpeoplewhomightbenefitbutwhohaven’treachedthestageofhavingaseriousmedicalproblem.”
3.5 Analysis of site data
Profile of the respondents
Atotalofforty-oneinitialRecoveryEvaluationForms(REFs)andtwelvefollow-upformswerecompletedfromBedfordshire(Flitwick),CamdenandCambridgeshire.Thesampleisrelativelysmallandacomparativelylimitedamountofquantitativeanalysiswasconducted.Thefollowingprovidesasnapshotoftheserviceuserswhocompletedtheevaluationforms:
Theaverageagewasforty-twoyearsold(range20-72),andthemajorityofpeopletakingpartwerefemale(71%).ArangeofethnicminoritygroupsparticipatedincludingBritish(45%),African(17%),Caribbean(12%),andEuropean(10%).
Regardingtheworkingstatusofparticipants,43%werenotworkingbutintendedtointhefuture,19%werenotworkingandhappywiththat,14%wereworkingfulltime,11%werestudents,and6%wereworkingpart-time.
85%oftheparticipantsreportedbeingonregularmedication,theseincludedFluoxetine,ProzacandClozapine.32%reportedhavingaphysicaldisability.51%werelivingalone,and24%hadcaringresponsibilities.
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Impact of participating in an exercise programme
Theanalysisofthetwelvefollowupevaluationformsallowedaninsightintotheimpactofexerciseparticipation.Itdoesappearthatparticipationinaprogrammedoesbringsomestatisticallysignificantimprovements(onthebasisofserviceuserself-rating)inthefollowingareas:
• Confidenceregardingmakingdecisions.
• Recognitionofearlysignsofbeingunwell.
• Awarenessofwhatittakestokeepwellandhappy.
• Knowingwheretogethelp.
• Feelingthattheirphysicalhealthwasgood.
• Feelingthattheyhadenergyandenthusiasmfortheircurrentactivities.
• Thattheywereencouragedbystafftotrynewthings.
Fromtheanswersgiven,thereappearstobelittledifferencebetweenmenandwomensaveforthefollowingwherewomengavemuchhigherinitial(baseline)scores:
• Feelingthattheirphysicalhealthwasgood.
• Feelingthattheyhadbeenencouragedtomakedecisionsaboutexercise.
Views about the exercise scheme
TheREFformallowsrespondentstoaddadditionalcommentsabouttheexerciseschemeandsomeofthepointsnotedsuggestthatformosttheexperienceoftakingparthadbeenpositive,hadhelpedpeopletoloseweightandtoimprovetheirsenseofcoping.
Severalalsocommentedonlookingforwardtoactivitiesandthattheywerenowabletofocusandtosetthemselvesgoalsforwhattheywantedtoachieve.
3.6 Exercise referral schemes: do they work?
“Theschemehasgotmebackintothegym…Supportfromothersontheschemehasbeenareal boosttomoraleandanimportantfeaturethatshouldbecontinuedinthefuture…”
(ParticipantinFlitwickexerciseprogramme)
Thecurrentdeliveryofexercisereferralschemeswasexploredviaaseriesoffocusgroupmeetingsandindividualinterviews.Inaddition,asmallnumberofinterviewswereundertakenwithlocalstakeholderssuchascommissionerswithinthelocalprimarycaretrustandcountycouncilleisuredepartments.Thesemeetingsgatheredinformationabout:thedifferenttypesofexerciseactivityonoffer;howinformationisdisseminatedaboutschemes;howthosereferredhadheardabouttheirlocalscheme;participantviewsregardingwhattheythoughtworkswellandideasforimprovingthedeliveryofexercisereferralschemes.
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The activities on offer in exercise referral schemes
TherangeofactivitiesthatparticipantsintheCamdenfocusgrouphadbeenreferredtorangedfromgym-basedclassesincludingcircuits,badminton,Pilatesandyogathroughtoaquaaerobics,activewalksandkickboxing.Activitiesweremainlyindoorsandbasedonbookedclasses,thoughsomedrop-intypesofactivitywerealsomentioned.InBedford,agreaterfocusongym-basedactivitieswasapparent.
InbothCamdenandBedford,theimportanceofhavingapproachableandempathetic,well-trainedinstructorswasemphasised:peopletheparticipantsfelttheycouldgettoknow,whoweregoodatassessingpeople’scapabilitiesandskilledinencouragingthemtoworkwithintheirlimits.
Itwasalsonotedthathavingstaffonhandwho“knowwhoyouarebeforeyouturnup”makesjoininganexercisereferralprogrammelessdauntingandvariouscommentswerealsonotedregardingtheimportanceofstaffhavinganunderstandingofmentalhealthsincepeoplecan“gohighorfeelverydownafterwards”(afteranexerciseclass)–andstaffneedtobeabletosupportpeopleappropriatelythoughthis.
The benefits of exercise referral programmes
Alloftheinformantstotheevaluationwereverypositivethattheirparticipationinaprogrammehadarealdifferencetotheirlives.Seeingotherpeoplewasaprominenttheme,alsothathavingaregularplannedactivitywhichwasseenasgivingafocustothedayandareasontogooutintotheirlocalcommunity.Asoneparticipantnoted:
“Thesocialelementissuchabigpartofit…promisingsomeonethatyouwillmeetupwiththemnext week(atthenextclass)isarealmotivator…”
Avarietyofphysicalandpsychologicalbenefitswerealsoidentifiedincluding:
• Exercisegivingyouaboostorwhatonepersoncalleda“naturalhigh”.
• Feelingmentallyandphysicallystronger.
• Becomingmoreconfident(onepersontalkedofhowithadencouraged themtotakeupsomevoluntarywork).
• Weightloss–andalthoughseveralparticipantswereclearthatexercisedoesn’t replacetheneedformedication,itcanreallyhelpwithreducingtheweightgain thatcanresultfromregularmedicationuse.
Theincreaseinconfidenceandthebenefitsarisingfromthiswasfrequentlynotedandiswellillustratedbythefollowing:
“…findingthatIcouldcope–physicallyandmentally–alongwithher(theinstructor’s) encouragement–gavemeconfidence.SoIstarteddoingothersocialandphysicalactivitiestoo…”
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Theentiregroupthoughtthattakingpartinexercisebenefitedyoungandoldandsuggestedthatmoreshouldbedonetoencourageyoungerpeopletotakepart,especiallygiventheconcernsaboutobesityamongyoungpeople.
Intermsofwhetherparticipationinanexerciseprogrammewaslikelytohavealastingimpact,mostthoughtthatitwould–forexample,feedbackquestionnairescompletedbyallparticipantsintheFlitwickprogrammeindicatedthattheyintendedtocontinueusingthegymaftertheendofthetwelveweekcourseandintheCamdenfocusgroup,mostofthegrouphadnotdoneanexerciseprogrammebeforejoiningtheschemeandnearlyallintendedtocontinueattendanceoncetheireightweekprogrammewascomplete.
ItwassuggestedthatthiswasthetypicalpatterninCamden,hencethelongwaitinglist/fullclasses.Again,theimportanceofhavingempatheticstaffrunningtheclasseswasnoted,withthefollowingillustratingthevalueofsuchinput:
“Hisfriendly,professionalandgood-naturedapproachmeantthatIhavefeltconfidentfrom thestart…hehasbeentotallynon-judgemental…whilealsogivingmepositiveandsustained encouragementtobecomemoreactiveinawaythatIwillbeabletosustainwhenIamno longerpartoftheprogramme…”
Externalstakeholdercommentssupportedthesepositiveviewpoints,withtheimportanceofhavingamenuofexerciseoptionsavailableagainbeingnoted,toensurethatdifferentinterests,differentlevelsofphysicalabilityandtheneedforgreaterorlessstructuredprogrammesofexercise,areaddressed.
Publicising exercise referral schemes
Fromtheinformationgathered,itdoesappearthatdisseminationofinformationaboutexercisereferralschemesisstillquitepatchyandlimitedeveninareasofthecountrywithwell-establishedschemes.Avarietyofcommentswerenotedtotheeffectthatitwaslargelybyluckor“onthegrapevine”thatpeoplehadheardabouttheirlocalscheme,includingoneparticipantwhodescribedaskingforareferralaftershehadheardaboutanexercisereferralschemeinanotherareaofthecountry.
Furthermore,althoughhalfthegrouphadbeenreferredbytheirGP,mostfeltthatithadbeenmorethroughtheirownsuggestionratherthantheGPbeingproactiveandawareofwhatwasonoffer.Overall,theysuggestedthattherewasnolocalinformationandagenerallackofadvertising.
ThisfindingechoessomeoftheconclusionsreachedbytheCamden(MiddlesexUniversity)evaluationwhichnotes:
“Healthprofessionalsstatedthattheywouldlikemoreinformationaboutwhatpatientsactually getfromthescheme,intermsofactivitiesaswellashealthbenefits.”19
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OnekeysuggestionmadeforimprovingthissituationwasforGPstobeinvitedtovisittheparticipatingexercise/leisurecentrestoseewhatwasavailable.Thismightimprovetheirawarenessandencouragethemtorefermorepatientswhocouldbenefit.
Suggestions for raising awareness of exercise referral schemes
InadditiontotryingtoinvolveGPsmore,informantstotheevaluationmadethefollowingsuggestions:
• Distributionofinformationtothelocaldayhospitalsandvoluntarysector projectsworkinginthementalhealthfield.
• Provisionofinformationtolocalcolleges.
• Targetingoftheadulteducationsector.
• Regulardisseminationofinformationaboutthedifferentclasses andexerciseactivitiesofferedthroughascheme.
Suggestions for improving the delivery of exercise referral schemes
Inbusyareasorthosewithpopularexercisereferralschemes,someparticipantshadexperiencedalongtimebetweenbeingreferredandbeingseenforaninitialassessment.Whilstitwasrecognisedthatthissituationreflectedthehighnumbersofreferrals,itisalsoimportanttoemphasisethatthisreferralprocessisanimportantpartofengagingpeopleinexerciseanditisimportantthattheyarenotkeptwaitingtoolongotherwisethemomentumandconfidencetotakepartcanbelost.AgainthispointwasraisedintheCamdenevaluationwhichnotesthatatimedelaybetweenreferralandconsultationcanresultinpeopleattendingaconsultationbutnotstartinganexerciseprogrammeduetoreducedmotivation.
Likewiseverypopularclassesgetfullupandattendancecanberestrictedand/orpeoplehavetowait.Thisagainemphasisestheneedtohaveamenuofdifferentchoicesavailable.
Theconsistencyofinstructorswasstressed.Insomeschemes,thereareanumberofdifferentinstructors,someofwhomdotheinitialassessmentsandsometherunningofactualclasses.Itwassuggestedthatintermsofmakingpeoplefeelsupportedandcomfortable,whereverpossible,thereshouldbecontinuityofstaffingthroughouttheassessmentsessionandatleastthefirstfewclasses.
Someconfusionwasnotedaboutcomplicateddiscountandpaymentarrangements–theseschemesneedtobeclear,assimpleaspossible,andwellpublicised.
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Finallytherewassomedebateandmixedviewsabouttheuseoftimelimitedprogrammes(forexampleeightortwelveweeks)andaboutwhetherreferralviaahealthprofessionalisreallynecessaryorsimplyservestodetersomepeople.
Severaloftheintervieweesexpressedtheviewthatprogrammesshouldbemoreopen-endedtoallowmoreflexibleattendance,althoughtheyrealisedthatcapacitycouldbeanissueinrunningschemesthisway.Likewise,allowingpeopletoself-refermightencouragepeopletobecomeactiveearlierratherthanwaitingforphysicalorpsychologicalproblemstoreachthepointofrequiringprofessionalidentificationandreferral.
3.7 Key learning points from the evaluation and 2007 GP surveyregarding the development and delivery of exercise referral schemes
InformationgatheredthroughtheGPsurveyandevaluationhashighlightedboththepositiveoutcomesforthosetakingpartinexercisereferralprogrammesandalsosomeofthefactorsthatarecurrentlyrestrictingtheirdevelopmentandwideruse.
Withregardtowhatmaybeimpedingtheuseofexercisereferralschemes,probablythemostimportantfindingisthatover40%ofGPsreportedthattheydonothaveaccesstoaschemeintheirarea.Alongsidethis,18%reportedthatoverthelasttwoyears,theyhadnoticedanincreaseinthenumberofpatientswithmildtomoderatedepressionaskingaboutexerciseasasuitabletreatment,whichwouldsuggestthatpublicawarenessofthebenefitsofexerciseforthismentalhealthdifficultyhasgrown.
Fromtheevaluationdata,itwasapparentthatthebarriersfacingthedevelopmentanduseofexercisereferralschemesincludeamongstotherthings:
• Inconsistentdisseminationofinformationaboutschemesandlimitedknowledgeastowhat isofferedamongstpotentialreferrers.
• Financial/budgetaryconstraints.
• Whereschemesareverypopular,therecanbedelaysinthetimebetweenreferral andassessmentorclassescanbefull(withthegeneralpressureonbudgetsandpremises meaningthatitisdifficulttorunextraclasses).
• Timeconstraints(aprominentreasongivenforthenon-completionofexerciseprogrammes).
Intermsofthebenefitstothosetakingpart,thefollowingpointswerenoted:
• Involvementinanexercisereferralprogrammedoesappeartobring arangeofphysicalandpsychologicalbenefits.
• Engagementinsuchprogrammescanhelptotackletheisolationandsocialexclusionofpeople withmildtomoderatedepressionandtosupporttheformationofnewpeerrelationships.
• Improvedself-confidence,reducedanxietyandagreaterabilitytofocus, setgoalsandcompletetaskswerealsowidelyreported.
Siteevaluations
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Keyfactorsinthesuccessfuldeliveryofexerciseprogrammesincluded:
• Localreferrerswithunderstandingofwhatwasonofferandanabilitytojudge the‘righttime’inaperson’srecoverytosuggestareferraltoanexerciseprogramme.
• Goodlocalinformationaboutwhatisavailable,whatattendanceentailsandwhatthe programmescost,alongsidevariouseffectivedisseminationchannelssuchasGPsurgeries, localhealthcentres,librariesandothercommunitysettings.
• Apromptandclearreferralprocesswithminimumdelaybetweenreferralandinitialassessment.
• Individualisedsupportforthepersonastheyinitiallyengagewiththeprogramme andmotivationalsupportthroughout(highlightedinbothCamdenandCambridge’sevaluations asacrucialfactorinthecompletionofprogrammes).
• Consistencyofsupportthroughouttheassessmentprocessandatleastthefirst fewexerciseclasses.
• Experiencedexerciseleaderswiththeabilitytoempathisewithpeoplereferredformental healthneedsandtoadjustthedeliveryofaprogrammeorindividualexerciseclasstoaccount forvariationsinmood,confidenceandabilitytoconcentrate.
• Havingachoiceofexerciseoptionsavailable(notjustgym-basedoptions)thatspandifferent fitnesslevels,differentinterestsandareofferedatanappropriatepacetotheneedsoftheclient.
• Flexibilityinthetimesofexerciseclassesandvenuesused;withthelatterbeingofahighquality, withgoodlevelsofcleanlinessandagoodsupplyofequipment.
• Schemes/exerciseclassesofareasonablesizetopromotethesocialaspectsofengagement.
• Clearavenuesintootherexerciseactivitiesoncompletionoftheexercisereferralprogramme.
Siteevaluations
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4. Conclusion
Thisreporthasdemonstratedhoweffectiveexercisecanbeasareferraloptionforthosewithmildtomoderatementalhealthdistress.Exercisetherapyispotentiallybothaneffectivetreatmentfordepressionandaneffectivepromotioninterventionfordepressedpeople.Fortheindividual,controlintheirrecoveryjourneyisleftwiththeminanempoweringwayandalsothereareassociatedbenefitstophysicalfitnessandsocialinclusion.
Despiteagrowingawarenessofthebenefitsofexercise,amongsthealthprofessionalsandthepublic,therearesomesignificantbarrierstoovercomeintermsofensuringthatallareasofthecountryofferexercisereferralschemes;thatinformationaboutwhatisavailableismorewidelydisseminated,andthatwhatisprovidedisofhighquality,affordableandrunbyappropriatedtrainedandexperiencedstaff.
Continuityoftheexercisestaffwithinspecificprogrammesisimportantforconfidencebuildingandengagement,alongsidetheavailabilityofindividualisedsupportifthisisneeded–however,financialandtimeconstraintscanmakethisdifficultinsomeschemes.Flexibilityinthetimingsandvarietyofexerciseisalsoneededtomeetthewiderangingneedsofrefereesbutagain,budgetconstraintsmaymakethisdifficulttodeliver.
Onapositivenote,GPsarenowmoreawareofexercisereferralasanoption,withmoreGPsinthecurrentsurveythanin2004reportingthattheywouldrefertoasupervisedexercisereferralschemeandmanyofthosewhodidn’thavetheoptionstatingthattheywouldliketohaveit.
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5. Key recommendations
Thefindingsfromtheevaluationofasmallsampleofexercisereferralschemes,backedbyanupdatednationalsurveyofGPsinEnglandhighlightthatthereiswidespreadsupportforthewiderdevelopmentofexercisereferralschemesandthat:
• Iftheyweremorewidelyavailable,GPswouldrefertothemasakeytreatmentintervention foravarietyofconditionsincludingmildtomoderatedepression.Thiswouldnotonly promotethedeliveryofsupportinmainstream,non-stigmatisingsettingsbutalso mayhelptoreducetheuseofanti-depressantmedicationandtheresultingsignificantnational expenditureonprescriptiondrugs.
• Ifarangeofdifferentactivities,deliveredatvaryingpacesbysupportivestaffempathetic totheneedsofpeoplewithmentalhealthdifficulties,isoffered,peoplewithsuchneedswill notonlyusethembutwillreportpositivehealthandsocialoutcomes,andinmanycases willthensustainsomeformofexerciseactivity.
For the commissioners and referrers to exercise referral schemes:
• Acrossthecountry,theprovisionofexercisereferralschemesvariesandthereisaneedfor PrimaryCareTrusts(PCTs)andcommissionerstosupportthedevelopmentandfunding ofavariedrangeofexerciseactivitiesthatpeoplewithmentalhealthandotherhealthdifficulties canbereferredtobytheGPsandotherhealthprofessionals,ortheycanself-referto.
• Itisimportantthatsuchschemesareeitherfreeorcompetitivelypricedinorder tobeaffordabletothegeneralpopulation.
• Informationaboutwhatisavailable,whereitisbasedandhowpeoplecanaccess theschemeneedstobedisseminatedviathelocalfacilitiesmostfrequentlyused bythegeneralpublicsuchaslibraries,localpharmaciesaswellascommunity healthsettingssuchasGPsurgeriesandhealthcentres.
• Thegatheringofoutcomesmonitoringdataneedstobesupportedinordertofurtherdevelop andstrengthentheevidencebasefortheuseofexercisereferralschemes,whichinturnwillgive supporttothefuturecommissioningofsuchservices.
• GPsandotherhealthprofessionalsinthoseareaswherethereisanexercisereferral schemealreadyoperationalshouldbesupportedinreferringallpatientspresentingmild tomoderatedepressionandshouldnotconsideronlythosewithphysicalconcerns suchasobesityorcoronaryheartdisease.
• Allhealthprofessionalswhorefertoexercisereferralschemesneedtounderstandandbeable toexplainwhattheseschemescanoffer.ThedevelopmentofcloserworkinglinksbetweenGPs, practicenurses,othercommunitybasedhealthstaffandtheexercisestaffworkinginreferral schemesisrecommended.This,andtheagreementofclearandsimplereferralprotocols, willprovideavenuesfordevelopinganimprovedandsharedknowledgeofwhattheseschemes canoffer,towhomtheyarerelevantandatwhattimeinthecourseofaperson’smental orphysicalillnesstheschemesoughttobeoffered.
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For the providers of exercise referral schemes
• Avarietyofexerciseactivitiesneedtobeonoffer,notonlygym-basedprogrammes, tocaterfordifferentinterestsandlevelsoffitnessandactivity.Theseneedtobeavailable atdifferenttimesofthedayincludingintheearlyevenings.
• Thereneedstobecarefulplanningofsupportintheearlystagesofaperson beginninganexerciseprogramme,andthepacingoftheclass.Thesearebothimportant factorsinthesuccessfulengagementofpeopleintoexercisereferralprogrammes.
• Whereverpossible,schemesshouldaimtooffercontinuityofstaffingthroughanexercise programmeandtheavailabilityofindividualisedsupportwhererequired.
• Staffworkinginexercisereferralschemesneedtodevelopacloserworkingrelationship withthosewhorefertotheirschemes,inordertoshareinformationaboutwhatisonoffer, toprovidefeedbackastotheimpactofprogrammesonthosereferredandtoplantogether thepossiblefutureexerciseneedsofthoseindividualsinthelocalpopulation withmentalandphysicalhealthdifficulties.
For those using exercise referral schemes
• Insupportingthedevelopmentofawiderrangeofexercisereferralschemes, andtheactivitiesonoffer,opportunitiesforthosereferredtoschemestosharetheirviews andsuggestionsforimprovingschemesshouldbeactivelypromoted.
• Someusersofexercisereferralschemesmayalsobeinterestedinhelpingtoplanorrunnew activitiesandshouldbeencouragedtosharethiswishwiththestaffintheirlocalscheme.
Keyrecommendations
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6. Appendices
Appendix A: GP Survey
TheresultscontainedinthisreportarederivedfromaconfidentialquestionnaireplacedbytheMentalHealthFoundationonNOPWorldHealth’s‘GPNet’Service–anonlinesyndicatedmedicalomnibusconductedamongstanationallyrepresentativequota-basedsampleofGeneralPractitioners.Thisweb-basedsurveywasself-completedbyGPsduringNovember2007.TheconfidentialquestionnairewasdesignedandformattedbyNOPWorldHealthwiththeMentalHealthFoundation.
Semi-structuredquestionnairesweresetuponNOPsownserver.Emailinvitationsweresentouttoarandom‘rolling’sampleofapproximately2000GPs,allbeingmembersofDoctors.net.uk’swebcommunity.Fromthispoolofdoctorsanationallyrepresentative,quota-controlledsampleof200NHSGPscompletedthesurveyonline.Thesamplewasquota-basedonthedoctor’squalifyingage(pre-1990and1990onwards)andon11regionstoensurefullnationaldistribution.Eachdoctorwhowassentane-mailinvitationhadtheirownuniqueidentificationnumberhiddenwithinthesurveyURL(whichpreventsasurveybeingcompletedtwiceandallowsforapartlycompletedquestionnairetobefinishedatalaterdate).InadditiontothissurveyPINeachrespondentcouldonlyaccessthesurveyviaDoctors.net.uk’s(DNUK)websiteviatheirownuserIDandpasswordasaDNUKmember.Thuseachparticipatingdoctorhadtopassthroughtwolevelsofsecurityinordertocompletethesurvey.
AlltherespondentswhoparticipatedinthissurveywereGMClistedphysicianswhowerememberofDoctors.net.uk,theUK’sleadingproviderofonlineservicesexclusivelyfordoctors.
Thisonlinesurvey(reproducedinthefollowingpages)wasself-completedbyGPs,allofwhomweremembersofDoctors.net.ukduringtheperiod19th–20thNovember2004inclusive.
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Q1:Whenapatientpresentswithmildormoderatedepression,whatareyourmost commontreatmentresponses?
Pleaseselectuptoamaximumofthreetreatmentresponses,where‘1’=yourmostcommontreatmentresponse,‘2’=yoursecondmostcommontreatmentresponseand‘3’=yourthirdmostcommontreatmentresponse
Mostcommon(1)
2ndmostcommon
(2)
3rdmostcommon
(3)
Prescriptionofantidepressantmedication
Referraltocognitivebehaviouraltherapy
Referraltoanotherformofcounselling/psychotherapy
Referraltoasupervisedprogrammeofexercise
Referraltoalternative/complementarytherapies
Referraltoadietician
Other(pleasespecify)
Q2: Ingeneral,whichdoyoubelievearethemosteffectivestrategiesforpatients presentingwithmildormoderatedepression?
Pleaseselectuptoamaximumofthreestrategies,where’1’=themosteffectivestrategy,‘2’=thesecondmosteffectivestrategyand‘3’=thethirdmosteffectivestrategy
Mostcommon(1)
2ndmostcommon
(2)
3rdmostcommon
(3)
Antidepressantmedication
Cognitivebehaviouraltherapy
Otherformofcounselling/psychotherapy
Asupervisedprogrammeofexercise
Alternative/complementarytherapies
Dietarychanges
Other(pleasespecify)
Appendices
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Q3:Whichoneofthefollowingtermsbestdescribesyouropiniononthegeneral frequencywithwhichantidepressantsareprescribed?
Singleansweronly
Toooften Appropriately Toolittle?
Q4:Ingeneral,howeffectivedoyouconsiderthefollowingformsoftreatment areforpatientswithmildormoderatedepression?
Singleanswerforeachformoftreatment
Notatalleffective
Notveryeffective
Quiteeffective
Veryeffective
Antidepressantmedication
Asupervisedprogrammeofexercise
Q5: Ingeneral,whichoneofthefollowingformsoftreatmentdoyoubelieveismorelikely tohelpsomeonepresentingwithmildormoderatedepression?
Singleansweronly
Antidepressantmedication Asupervisedprogrammeofexercise
Q6: Accordingtothescaleshown,pleaseindicateyourlevelofagreement foreachofthefollowingstatements.
Singleanswerforeachstatement
Stronglydisagree
Disagreeeffective
Agreeeffective
Stronglyagree
Antidepressantmedicationsarenotaseffectiveasthepublicthinkstheyare
Mostpatientswhoaregivenantidepressantswouldbeaslikelytogetbetteriftheywereunknowinglyprescribedaplacebo
Antidepressantsarenotgenerallyeffectiveasatreatmentformildtomoderatedepressionunlessusedaspartofawider,individuallytailoredcarepackage
Appendices
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Q7:Ifothertreatmentresponsestomildormoderatedepression(suchascognitivebehavioural therapies,otherformsofcounselling/psychotherapy,exercisereferralschemes orcomplementarytherapies)weremoreavailabletoyou,whichoneofthefollowing statementswouldbestdescribehowwouldyouprescribeantidepressants?
Singleansweronly
Lessfrequentlythannow
Asfrequentlyasnow,inadditiontoincreasedusageofothertreatmentresponses
Asfrequentlyasnow–butwithoutincreasedusageofothertreatmentresponses
Morefrequentlythannow
Q8:Inthelastthreeyears,haveyouhadcausetoprescribeanantidepressantdespite believingthatanalternativetreatmentmighthavebeenmoreappropriate?
Yes>Q9No>Q10
Q9: Whydidyouprescribeantidepressantsinthis/thesecase(s)?
Pleaseselectallthatapply
Thepatientrequestedaprescriptionforanantidepressant
Suitablealternativetreatment(s)was/werenotavailabletome
Thepatientwasnotwillingtotrythealternative(s)offered
TherewasawaitinglistforsuitablealternativetreatmentsoIprescribed anantidepressanttoprovideanimmediateresponseintheinterim
Other(pleasespecify)
Appendices
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Q10: Ifyoubecamedepressedyourself,whichofthefollowingtreatment strategieswouldyoumostlikelyuse?
Pleaseselectuptoamaximumofthreestrategies,where’1’=yourfirstchoicestrategy,‘2’=yoursecondchoicestrategyand‘3’=yourthirdchoicestrategy.
1stchoice(1) 2ndchoice(2)
3rdchoice(3)
Antidepressantmedication
Cognitivebehaviouraltherapy
Otherformofcounselling/psychotherapy
Aprogrammeofexercise
Alternative/complementarytherapies
Dietarychanges
Other(pleasespecify)
Q11: Ifmoneywerenoobject,whichofthefollowingstrategiesdoyouthinkwould bethemostusefultoimplementinordertoreducetheincidenceofdepressionamongst primarycarepatientsintheUnitedKingdom?
Pleaseselectuptoamaximumoffivestrategies,where‘1’=themostusefulstrategy,‘2’=thesecondmostusefulstrategyetc
Mostuseful(1)
2ndmostuseful(2)
3rdmostuseful(3)
4thmostuseful(4)
5thmostuseful(5)
Longerconsultations
Greateraccesstocognitivebehaviouraltherapy
Greateraccesstootherformsofpsychotherapyandcounselling
Greateraccesstosupervisedexerciseschemes
Greateraccesstocomplementarytherapies
Greaterinvestmentinimprovingpatients’socialsupports–(suchasinimprovedhousing,greateremploymentopportunities,reducingpoverty)
Greaterinvestmentinpublicmentalhealthpromotioncampaigns
Appendices
Moving on up38
Mostuseful(1)
2ndmostuseful(2)
3rdmostuseful(3)
4thmostuseful(4)
5thmostuseful(5)
GreaterinvestmentinGPmentalhealthtraining
Greaterinvestmentinresearchtoevaluateandimproveantidepressantmedication
Greaterinvestmentinresearchtoevaluateandimprovenon-pharmacologicalinterventions,suchascognitivebehaviouraltherapy,otherpsychotherapyandcounselling,diet,exercise,alternative/complementarytherapies)
Other(pleasespecify)
Q12:Doyouhaveaccesstoanexercisereferralschemeforyourpatients?
Yes > Q13
No > Q14
Don’tknow > Q14
Q13:Onaverage,howoften,ifatall,doyouusetheexercisereferralscheme forpatientswithmildormoderatedepression?
Singleansweronly
Veryfrequently > Q16
Fairlyfrequently > Q16
Notveryfrequently > Q15a(1)
Never > Q15a(2)
Q14: Ifanexercisereferralschemewereavailabletoyou,howoften,ifatall, wouldyouconsiderusingitforpatientswithmildormoderatedepression?
Singleansweronly
Veryfrequently > Q16
Fairlyfrequently > Q16
Notveryfrequently > Q15a(1)
Never > Q15a(2)
Appendices
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Q15a(1):Whydo(would)younotusetheexercisereferralschememorefrequently forpatientswithmildormoderatedepression?
or
Q15a(2):Whydo(would)youneverusetheexercisereferralschemeforyour patientswithmildormoderatedepression?
Pleaseselectallthatapply
Iamnotconvincedthatexerciseisaneffectivetreatmentresponse formildormoderatedepression
Idon’t/wouldn’thavetimetoaddexercisereferraltomyprescribingrepertoire
Idon’t/wouldn’twanttobesuedifthepatientinjureshim/herselfbyexercisinginappropriately
Mostofmypatientswithmildormoderatedepressionaren’t/wouldn’tbeeither ableorwillingtocarryoutaprogrammeofexercise
Mostofmypatientswithmildormoderatedepressionexpecttobegiven antidepressantsasatreatmentresponsetodepression
Idonotbelievethataddingexercisereferraltomycurrentrangeoftreatmentresponseswould makeasignificantdifferencetothewell-beingofmypatientswithmildtomoderatedepression
Idon’thaveenoughtrustinexercisereferralschemestohandlemypatientssafelyandeffectively
Itwouldn’toccurtometouseanexercisereferralschemeforpatients withmildtomoderatedepression
TheexercisereferralschemetowhichIhaveaccessdoesnotpermit metoreferpatientswithmildtomoderatedepression
Other(pleasespecify)
Appendices
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Appendix B: Evaluation Form
ThisquestionnairehasbeendesignedtocaptureinformationtoimproveadultexerciseschemesinNorthamptonshireandallinformationisconfidential.
Client Number:
Name of exercise service
Today’s date
Baseline or follow-up
Foreachofthefollowingquestionspleasecircleoneoftheanswersaccordingtohowyoufeel
SA=StronglyAgree A=Agree N=Neutral D=Disagree SD=StronglyDisagree
1 IhavegoalsIamworkingtoachieve SA A N D SD
2 Ihaveenergyandenthusiasmformycurrentactivities SA A N D SD
3 Ifeelhopefulaboutmyfuture SA A N D SD
4 Iamawareofmypersonalskills,talentsandstrengths SA A N D SD
5 IfeelconfidentinmakingmyowndecisionsaboutwhatIwant
SA A N D SD
6 IhaveconfidencethatIcancopeifsituationsbecomedifficult
SA A N D SD
7 IcanrecognisetheearlysignsifIambecomingunwell SA A N D SD
8 I’mawareofwhatittakestokeepmewellandhappy SA A N D SD
9 IknowwheretogethelpifIneedit SA A N D SD
10 Myphysicalhealthisgood SA A N D SD
11 IamhappywithwhereIlive SA A N D SD
12 Icanmanagemycurrentfinancialsituation SA A N D SD
13 Ihaveagoodsocialnetworkandstrongfriendships SA A N D SD
14 IamabletopracticeanyspiritualorreligiousbeliefsImayhave
SA A N D SD
15 Thereismeaningfulactivityinmylife(ahobby,aninterestIenjoy)
SA A N D SD
16 Ifeelsupportedbymyfamily SA A N D SD
The exercise service you receive:
17 Ifeellistenedtobythestaff SA A N D SD
18 Theserviceprovidesmewithinformationregardingthebenefitsofexerciseonmyemotionalwell-being
SA A N D SD
19 Iamencouragedtomakethedecisionsaboutmyexerciseprogram
SA A N D SD
20 Thestaffareawareofmyemotionalstrengths SA A N D SD
Appendices
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21 Thestaffencouragemetotrynewthings SA A N D SD
22 IcanattendtheservicewhenIneedto SA A N D SD
23 Theserviceisimportantingivingmehopeforthefuture SA A N D SD
Please only answer Questions 25 & 26 if you have completed your exercise program
24. Wouldyourecommendtheexerciseprogramyouhavejustattendedtoafriend?
Yes No Don’tKnow
25.Wouldyouaccessotherexerciseprogramsinthefuture?
Yes No Don’tKnow
About you. Please fill out the in the following as best describes you.
26.Gender: Male Female
27.Ageinyears:
28.IsEnglishyour1stlanguage: Yes No
29.Ethnicity:
Pleaseonlytickonebox,ifyourethnicityisnotstatedinthecategoriesbelow,thenpleasewriteitinthe‘other’box.
White Mixed Asian/AsianBritish
Black/BlackBritish
Chinese/otherethnicgroup
British WhiteandBlackCaribbean Indian Caribbean Chinese
Irish WhiteandBlackAfrican Pakistani African
WhiteandAsian BangladeshiOther
30.Doyoulivealone? Yes No
31.Doyouhavecarerresponsibilities? Yes No
32. Doyouhaveanyphysicaldisabilities? Yes No
IfYes,pleasestate:…………………………………………………………………………………
33. Areyouonanyprescribedmedication? Yes No
IfYes,pleasestate:…………………………………………………………………………………
Appendices
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34.Areyoureceivinganyothertypeofsupportforyouremotionaland/ormentalwell-being?
Yes No
IfYes,pleasestate:
35. Employment&Education:
Iamworkingfulltime Iamnotworking,butseemyselfworkinginthefuture
Iamworkingparttime Iattendcollegeoraneducationalprogramme
Iamdoingvoluntarywork Iamnotworkingandamhappywithmylife
36. Inwhatwaysdoyouthinktheexercisehashelpedyou?
Appendices
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Appendix C: Project information sheet
An evaluation of Exercise on Referral schemes in selected areas of England
Version 1, February 14th 2008 Protocol reference: 08/H0720/26
Participantinformationform(shortversion)DRAFT
AcrosstheUK,therehasbeenaconsiderablegrowthofexercisereferralsschemes,ofteninresponsetothegreaterawarenessandevidencewenowhaveofthebenefitsofexercisenotonlyinpromotinggoodphysicalhealthbutalsogoodmentalhealthandwell-being.
TheMentalHealthFoundation,anationalmentalhealthcharity,hasbeenfollowingthisissueforsomeyears.ItisworkingwithpeopleinbothhealthandexerciseservicestochampionthedevelopmentofexercisereferralschemeswherebyhealthprofessionalssuchasGPscanrefertheirpatients,inparticularthosewhomayhavemildtomoderatedepression,toanexercisescheme.
Thisprojectiscalled‘UpandRunning?’andasapartofthework,thecharityisgatheringinformationaboutdifferentexercisereferralschemes–howtheywork,whattheyoffer,howmuchtheycharge,howmanypeopleareusingthemandwhetherthepeopletakingpartfeelthattheyarehelpful.
In(nameofarea),anexercisereferralschemehasbeenrunningforsomeyears/hasjustbeensetup(textwillbedeleteddependingonwhatapplies)andstaffintheschemewillbehelpingtheMentalHealthFoundationbysendingsomeinformationaboutwhattheyoffer.Thiswillincludesomeofthefigurestheyroutinelycollectabouthowmanypeopleusetheexerciseclasses,whorefersthemandthefeedbackpeoplegiveabouttheexerciseactivitytheyhavetakenpartin.Itwillnotbepossibletoidentifyanyindividualsfromthisinformationwhichwillbeusedforareportdescribinghowexercisereferralschemesarebeingrunandhowwelltheywork.
Theinvolvementof(nameofarea)shouldnotinanywayaffecthowtheexerciseactivitiesareoffered,andasbefore,thecompletionofanyself-reportingformsbyanyonetakingpartinanexerciseactivityisentirelyvoluntary.However,ifyouhaveanyquestionsorconcernsabouttheexercisevenueyouattendbeinginvolvedinthe‘UpandRunning?’project,youarewelcometocontacttheFoundation’sinvestigatorXXXXonXXXXwhowillbehappytoexplainmoreabouttheproject.
Appendices
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7. References
1. Biddle,S.J,&Mutrie,N(2001)Psychologyofphysicalactivity:Determinants,well-beingandinterventions.
2. McCormick,B,Frey,G,Lee,C,Chun,S,Sibthorp,J,Gajic,T,Stamatovic-Gajic,B&Maksimovich,M.(2008)Predictingtransitory moodfromphysicalactivitylevelamongpeoplewithseverementalillnessintwocultures.TheInternationalJournalofSocial Psychiatry,vol54(6),527-38.
3. Deihl,J&Choi,H(2008)Exercise:thedataonitsroleinhealth,mentalhealth,diseasepreventionandproductivity. PrimaryCare,vol35(4),803-16.
4. Taylor,A&Fox,K(2005)EffectivenessofaPrimaryCareExerciseReferralInterventionforChangingPhysicalSelf-Perceptionsover 9months.HealthPsychology,vol24(1),11-21.
5. Lawler,D&Hopker,S(2001)Theeffectivenessofexerciseasaninterventioninthemanagementofdepression:systematic reviewandmeta-regressionanalysisofrandomisedcontrolledtrials.BritishMedicalJournal,vol322,763-767.
6. Sutherland,J,Sutherland,S&Hoehns,J(2003)Achievingthebestoutcomeintreatmentofdepression.TheJournalofFamily Practice,vol52(3),201-209.
7. Ma,W,Lane,H&Laffrey,S(2008)AmodeltestingfactorsthatinfluencephysicalactivityforTaiwaneseadultswithanxiety. ResearchinNursing&Health,Vol31(5),476-489
8. Sims,J,Galea,M,Taylor,N,Dodd,K,Jespersen,S,Joubert,L,Joubert,J.(2009)Regenerate:assessingthefeasibilityofastrength- trainingprogramtoenhancethephysicalandmentalhealthofchronicpoststrokepatientswithdepression.International JournalofGeriatricPsychiatry.Vol24(1)76-83.
9. Wand,T&Murray,L(2008)Let’sgetphysical.InternationalJournalofMentalHealthNursing.Vol17(5),363-9.
10. Carless,D&Douglas,K(2008)SocialSupportforandThroughExerciseandSportinaSampleofMenwithSeriousMentalIllness. IssuesinMentalHealthNursing,vol29(11),1179-1199.
11. Diaz,A&Motta,R(2008)Theeffectsofanaerobicexerciseprogramonposttraumaticstressdisordersymptomseverityin adolescents.InternalJournalofEmergencyMentalHealth,vol10(1),49-60.
12. NorthamptonshireCountyStandardProtocolDecember2007
13. NationalInstituteforClinicalExcellence.ClinicalGuideline23:depression:managementofdepressioninprimary andsecondarycare.London:NICE.
14. DepartmentofHealth(2004)Atleastfiveaweek:Evidenceontheimpactofphysicalactivityanditsrelationshiptohealth
15. DepartmentofHealth(2005)ChoosingActivity:Aphysicalactivityactionplan.
16. MentalHealthFoundation(2005)UpandRunning?Exercisetherapyandthetreatmentofmildormoderate depressioninprimarycare.
17. Stathi,A;Milton,K.andRiddoch,C.(2006)EvaluationoftheLondonBoroughofCamdenExerciseReferralScheme MiddlesexUniversity,LondonSportInstitute
18. Stathi,A;Milton,K.andRiddoch,C.(2006)EvaluationoftheLondonBoroughofCamdenExerciseReferralScheme. MiddlesexUniversityLondonSportInstitute.
19. Stathietal(2006)OpCit
Registeredcharitynumber(England)801130(Scotland)SC039714©MentalHealthFoundation2009 ISBN978-1-906162-36-8
www.mentalhealth.org.uk
Mental Health Foundation9thFloor,SeaContainersHouse20UpperGroundLondon,SE19QB02078031100mhf@mhf.org.uk
Scotland OfficeMerchantsHouse30GeorgeSquareGlasgow,G21EG01415720125scotland@mhf.org.uk
Foundedin1949,theMentalHealthFoundationistheleadingUKcharityworkinginmentalhealthandlearningdisabilities.
Weareuniqueinthewaywework.Webringtogetherteamsthatundertakeresearch,developservices,designtraining,influencepolicyandraisepublicawarenesswithinoneorganisation.Wearekeentotackledifficultissuesandtrydifferentapproaches,manyofthemledbyserviceusersthemselves.Weuseourfindingstopromotesurvival,recoveryandprevention.Wedothisbyworkingwithstatutoryandvoluntaryorganisations,fromGPpracticestoprimaryschools.Weenablethemtoprovidebetterhelpforpeoplewithmentalhealthproblemsorlearningdisabilities,andpromotementalwell-being.
Wealsoworktoinfluencepolicy,includingGovernmentatthehighestlevels.Weuseourknowledgetoraiseawarenessandtohelptacklestigmaattachedtomentalillnessandlearningdisabilities.Wereachmillionsofpeopleeveryyearthroughourmediawork,informationbookletsandonlineservices.Wecanonlycontinueourworkwiththesupportofmanyindividuals,charitabletrustsandcompanies.Ifyouwouldliketomakeadonation,pleasecalluson02078031121.
Visitwww.mentalhealth.org.ukforfreeinformationonarangeofmentalhealthissuesforpolicy,professionalandpublicaudiences,andfreematerialstoraiseawarenessabouthowpeoplecanlookaftertheirmentalhealth.
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