moving on up - mental health foundation · moving on up 01 contents acknowledgements ... that if...
TRANSCRIPT
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
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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,[email protected]
Scotland OfficeMerchantsHouse30GeorgeSquareGlasgow,[email protected]
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.