Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 2000 May 27;320(7247):1470.

The Newcastle exercise project

Conclusions are misleading

Ngaire Kerse 1,2, Sue Walker 1,2
PMCID: PMC1127654  PMID: 10877560

Editor—We welcome the article by Harland et al on promoting physical activity in primary care but dispute the conclusion that these schemes are of questionable effectiveness.1 The title for the paragraph for This week in the BMJ that “exercise on prescription” is a waste of scarce resources is also misleading and not justified by evidence to date.

Our response stems from concerns about their intervention approach and our experience in two research endeavours: implementing a physical activity prescription scheme in New Zealand and a recently published randomised controlled trial resulting in long term improvement in physical activity for older people.2

Firstly, we question whether the level of intervention with the control group (information and recommendations about activity) resulted in a comparison with a lesser intervention, rather than a true control group, perhaps underestimating the efficacy of exercise counselling.

Secondly, is lengthy motivational interviewing appropriate and replicable in a general practice setting? This approach is time intensive for general practitioners and practice nurses and perhaps limits effective long term follow up. In New Zealand 51% of general practitioners are prescribing physical activity through the Hillary commission's “green prescriptions” scheme.3 One of the barriers to exercise prescription is lack of time during the consultation.4,5 We contend that interventions that are quick and simple to implement with regular practice based reinforcement offer more potential for sustainability and long term effectiveness.

Individualised assessment and programme design benefit outcome in health promotion trials. The judgment of the general practitioner is key in this area. The intervention design of a recent successful randomised controlled trial, set in Melbourne, Australia,2 raised the consciousness of the general practitioner through an effective educational programme, but it left the details of whom to target and the exact content of advice to the professional judgment of the general practitioners. In Newcastle the general practitioners seemed to be virtual bystanders to the design and delivery of the intervention. We contend that the skills of the general practitioners should play a central part in physical activity interventions.

We recognise the need for outcome based evaluations in this area of health promotion. A three year study has begun in New Zealand, which evaluates the long term effectiveness of green prescriptions in increasing physical activity and improving cardiovascular risk index and quality of life of middle aged and older people at risk from physical inactivity, by comparing the intervention with a true control group that receives no advice.

Exercise on prescription a waste of scarce resources? We await the evidence to answer this question.

References

  • 1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Kerse NM, Jolley D, Arroll B, Flicker L, Young D. Improving health behaviours of the elderly: a randomised controlled trial of a general practice educational intervention. BMJ. 1999;319:683–687. doi: 10.1136/bmj.319.7211.683. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.IMS Health (NZ) Green prescriptions in general practice. Summary report, November 1999. Auckland: IMS NZ; 1999. . (Available from Intercontinental Medical Statistics, Level 1, ASB Hurstmere Building, 33-45 Hurstmere Road, Takapuna, Auckland, New Zealand.) [Google Scholar]
  • 4.Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. Green prescriptions: attitudes and perceptions of general practitioners towards prescribing exercise. Br J Gen Pract. 1997;47:567–569. [PMC free article] [PubMed] [Google Scholar]
  • 5.Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners. Am J Public Health. 1998;88:288–291. doi: 10.2105/ajph.88.2.288. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Jury is still out

Marko Petrovic 1,2,3, Jeremy Corson 1,2,3, Lyndon Miles 1,2,3, Elwyn Williams 1,2,3, Hilary Fielder 1,2,3

Editor—Harland et al have made a valuable contribution to the evidence base that currently underpins the promotion of physical activity.1-1 We are concerned that several features of their study may reduce the external and internal validity of the conclusions that have been reached.

The study described does not examine an exercise on prescription scheme. All patients aged 40-64 attending surgeries were approached and considered. This is, therefore, a population sample, not a targeting of selected patients by a general practitioner. Furthermore, because the response to this initial invitation to participate was low, those who agreed to participate may have been the most enthusiastic and not representative of the general population. This may have reduced both the likelihood of proving the effectiveness of the intervention and the validity of the findings with respect to the general population.

The interventions that were evaluated were very intensive and are unlikely to be feasible in an average primary care setting. In addition, whereas the specific method of promoting physical activity is undoubtedly an important issue, it does not stand alone. It is also necessary to consider broader social factors that may mask the effect of an intervention at this level. These would include the availability of time to attend and the accessibility of facilities.

The authors have based sample size calculations on the number of participants that would be required to detect a difference between success rates of 40-60%. In addition to the fact that the required number of participants was not met, the prospect of achieving such a large difference in success rates seems rather ambitious.

Although we agree with the authors' conclusion that further research is necessary to develop interventions that promote long term adherence to exercise, it is important that the exercise on prescription scheme is differentiated from population strategies that attempt to raise the level of exercise generally.

References

  • 1-1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Headline for This week in the BMJ is misleading

Frank Smith 1,2, Jane Sims 1,2

Editor—We would like to take issue with the title of the paragraph for This week in the BMJ, “‘Exercise on prescription’ is a waste of scarce resources,” for Harland et al's article on physical activity.2-1 The article showed that all four intervention groups showed a significant increase in self reported activity at 12 weeks, compared with a control group that increased reported activity in 16%. In addition there was a suggestion of a dose-response effect as the greatest increase was seen in the group with financial inducement and multiple interventions. It was a pity that Harland et al did not report on the physiological and exercise test outcomes in this paper.

The control group had in effect a brief intervention akin to an exercise prevention. This trial produced no evidence that more intense intervention in the short term produces sustained effects, as reflected by the findings at one year. This is not surprising given the trial design. Numerous other studies2-2–2-4 show that frequent contact with the subjects, even by brief telephone calls, limits dropouts and that perhaps at least six months of professional contact is needed before the increased physical activity pattern becomes incorporated into behaviour. The key seems to be not so much intensity of contact but continuity over time. Such continuity is a feature of general practice; this should remain an arena for testing such interventions.

Harland's trial shows that in general practice in the United Kingdom patients may be recruited from a comparatively deprived inner city area, and their physical behaviour can be increased by intervention from a researcher, mirroring encouraging trials with primary care doctors from the rest of the world.2-5 What they have not shown is how to maintain the increased activity. This requires further studies, and we believe that the headline is misleading and discouraging to researchers and funding authorities.

References

  • 2-1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Murdo ME, Burnett L. Randomised controlled trial of exercise in the elderly. Gerontol. 1992;36:292–298. doi: 10.1159/000213343. [DOI] [PubMed] [Google Scholar]
  • 2-3.Hamdorf PA, Withers RT, Penhall RK, Plummer JL. A follow up study on the effects of training on the fitness and habitual activity patterns of 60-70 year old women. Arch Phys Med Rehab. 1993;74:473–477. doi: 10.1016/0003-9993(93)90108-m. [DOI] [PubMed] [Google Scholar]
  • 2-4.King A, Haskell W, Taylor C, Kraemer H, DeBusk R. Group- vs home-based exercise training in healthy older men and women. A community based clinical trial. JAMA. 1991;266:1535–1542. [PubMed] [Google Scholar]
  • 2-5.Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners. Am J Public Health. 1998;88:288–291. doi: 10.2105/ajph.88.2.288. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Key messages are misleading and conclusions are not evidence based

Nanette Mutrie 1,2,3,4, Catherine Woods 1,2,3,4, Mathew Lowther 1,2,3,4, Avril Blamey 1,2,3,4, Christopher Loughlan 1,2,3,4

Editor—We welcome the addition of this study to the debate on the efficacy of exercise referral, but we believe that Harland et al have asked the wrong questions and therefore drawn the wrong conclusions.3-1

Harland et al wanted to know whether there was a difference between the various interventions and control in changes in physical activity score from 12 weeks to one year. Since there were no differences, the headline for This week in the BMJ stated that prescription of exercise is a waste of scarce resources. A better question would be to ask whether any group had increased their activity at one year compared with baseline. According to the data Harland et al present in table 2, the percentage of participants who had increased physical activity scores at one year compared with baseline ranged from 23% in the control group to 31% in intervention 3. If these are significant changes from baseline then the conclusion might have been that even the control condition can have a substantial impact in increasing physical activity over one year. Further economic analysis might then determine that the control (which seemed to include the basis of many intervention techniques such as assessment, feedback, and the provision of information) was the most cost effective intervention. The authors' conclusion that brief interventions are of questionable effectiveness is wrong since none of their interventions or even the control condition could be described as brief. In our own research we have shown that much briefer interventions (provision of an information booklet alone) can still increase physical activity up to six months.3-2

The outcome measures also asked the wrong questions since they were based on an outdated questionnaire. A better option would have been to determine whether participants had achieved the current targets for sedentary individuals of accumulating 30 minutes of moderate activity on most days of the week.3-3,3-4

The authors claim that the research is based on the stage of change model. However, they have not reported how interventions were tailored to stages, any details of pre-intervention or post-intervention stages, the effectiveness of interventions by stage, or the other crucial elements of this model such as the processes of change and self efficacy measures.3-5

These flaws mean that the key messages are misleading and that the conclusions drawn are not evidence based. Such misinterpretation could severely limit future research and service developments.

References

  • 3-1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Loughlan C, Mutrie N. An evaluation of the effectiveness of three interventions in promoting physical activity in a sedentary population. Health Educ J. 1997;56:154–165. [Google Scholar]
  • 3-3.Scottish Office. Towards a healthier Scotland—a white paper on health. Edinburgh: Stationery Office; 1999. [Google Scholar]
  • 3-4.Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402–407. doi: 10.1001/jama.273.5.402. [DOI] [PubMed] [Google Scholar]
  • 3-5.Marcus BH, Eaton CA, Rossi JS, Harlow LL. Self-efficacy, decision-making, and stages of change: an integrative model of physical exercise. J Appl Soc Psychol. 1994;24:489–508. [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Organisational aspects may influence adherence rates

Julia Critchley 1,2,3, Anthony J Isaacs 1,2,3, Rochelle Rosenthall 1,2,3, Lorraine Honeybell 1,2,3, Chris Smith 1,2,3

Editor—Harland et al report on a randomised controlled trial of methods to promote physical activity in primary care.4-1 The most intensive intervention was not effective in increasing physical activity at one year follow up, which highlights the need to develop interventions that promote long term adherence.

A further randomised controlled trial of a referral programme for physical activity in primary care is currently under way in Barnet (EXERT study). Participants are randomised to one of three treatment arms: tailored advice (control group), leisure centre based exercise classes, and a more community based walking programme. Patients aged 40-74 with at least one cardiovascular risk factor are eligible for inclusion. Currently 600 have been randomised; we expect to recruit over 1000. All recruits receive a detailed assessment before randomisation, including measurement of blood pressure, blood lipid concentrations, anthropometric variables, cardiovascular fitness, psychological status, and quality of life. Follow up with similar tests is carried out at the end of the exercise programme, after six months, and at one year.

Table.

Comparison of uptake of classes in Newcastle and EXERT study

Newcastle EXERT
Proportion of patients attending at least one session 0.41 0.86
Proportion of all available sessions attended 0.12 0.50
Mean No of sessions attended per week* 0.78 1.26
Open in a new tab
4-150

By those attending at least one session. 

The Barnet programme differs from the Newcastle trial in several organisational aspects that may influence longer term adherence rates. Both intervention arms are run as a series of cohorts, with participants starting and finishing the 10 week programme at the same time. They are also led by instructors and designed specifically for the patient population. Hence, the extent of motivation and support offered is much higher; participants can potentially see the same instructor several times a week. Participants report enjoying the social element of the programme, particularly the fact that classes contain only referrals from general practitioners. A lack of designated classes may explain the low uptake of vouchers in the Newcastle scheme, compared with a higher participation in EXERT (table).

A further methodological issue discussed is the possible motivational effect on controls of a baseline assessment. The EXERT study will allow evaluation of the effect of a “fitness test,” as 50% of participants from each arm are randomised to receive this at 10 weeks, while the remainder have no additional measurements between baseline and six months.

This design offers an alternative model for promoting physical activity. The study will have included sufficient numbers of patients to enable an interim report on adherence for comparison with the results of the Newcastle study later this year.

Acknowledgments

The EXERT study is funded by the NHS Health Technology Assessment Programme.

References

  • 4-1.Harland J, White M, Drinkwater C, Chinn D, Farr R, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Group support is crucial to success

Peter J S Baker 1

Editor—I applaud Hartland et al for attempting to appraise the efficacy of exercise prescription by general practitioners.5-1 The programme they studied in Newcastle is, however, unlikely to achieve long term changes in lifestyle because it is flawed. Compliance will be achieved only if participants go through their exercise programme in mutually supportive groups.

A scheme in mid-Devon in which participants felt part of a group of about 15 has been popular and successful. In 1994 a health prescription scheme was started in Cullompton, a market town in Devon with a population of about 6000. Altogether 33 general practitioners with a total of 47 855 patients on their lists were invited to participate in the scheme, and 474 patients were referred to the Culm Valley Sports Centre in a 12 month period in 1995-6 for the following reasons in rank order: general unfitness, overweight, depression or fatigue, back pain, heart surgery, injury, arthritis or immobility, hypertension, neurological problems, and diabetes. The programme was set up by a physiotherapist and an exercise trainer, who was dedicated full time to the scheme.

Funds for additional equipment were provided by Mid-Devon District Council. Participants paid reduced charges (£1.95 instead of £2.60) and in groups of about 10 attended twice a week for 10 weeks at off-peak times. They had a free initial assessment (usual cost £9), which included measurement of blood pressure, pulse rate before and after exercise, body dimensions, fat thickness, and peak flow. Despite the reduction in charges the scheme has been self funding.

Fox et al studied exercise prescription schemes and included the following among the advantages5-2:

  • Ease with which general practitioners can contribute

  • Willingness of leisure centre to take on responsibility

  • Availability of expertise and facilities

  • Popularity among patients

  • Motivational effect of group exercise

  • Financial viability.

The mid-Devon scheme corroborates these. Functional and psychological benefits were seen in patients with chronic back pain assessed by using a visual analogue scale, the Oswestry low back disability questionnaire, and the hospital anxiety and depression scale. Delays are minimal, which is an obvious benefit when deconditioning is taking place. At times there may be positive advantages in removing some people from the medical arena. The motivational effect of cohesive and mutually supportive groups is crucial to the success of exercise prescription schemes.

References

  • 5-1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;7213:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-2.Fox K, Biddle S, Edmunds L, Bowler I, Killoran A. Physical activity promotion through primary care in England. Br J Gen Pract. 1997;47:367–369. [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Excluded patients should be encouraged to take up exercise

Marion McMurdo 1

Editor—Harland et al report on an attempt to promote physical activity in one general practice.6-1 Their choice of sessions of vigorous activity as part of their main outcome measure was a surprising perpetuation of a common misconception.

It has been clear for some time that regular physical activity at moderate (rather than vigorous) intensity provides substantial health benefits and that activity at low to moderate intensity is more likely to be continued than activity at high intensity.6-2,6-3 In addition, levels of habitual physical activity in the general population are so low that to most people the prospect of vigorous activity is a big turnoff. Given that the health benefits gained from increased activity depend on the initial level of activity, a more valuable approach would have been to focus on the number of subjects achieving the transition from sedentary state to regular physical activity at moderate intensity.

We accept that the entry criteria to a research project may not always reflect practice in the real world, but the fact that Harland et al excluded one third of patients from participation on health grounds seems like another lost opportunity. Most adults do not need to see their doctor before starting a programme of physical activity at moderate intensity.6-4 Those subjects excluded by Harland et al because of acute myocardial infarction within the previous 12 months, angina, and cerebrovascular disease are precisely the group that should be receiving strong positive encouragement from their doctors to be regularly physically active.6-5

Acknowledgments

Professor McMurdo is codirector of D D Developments, a University of Dundee company whose mission is to provide exercise classes for older people and whose profits support research into ageing and health.

References

  • 6-1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howell D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6-2.Physical Activity and Public Health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402–407. doi: 10.1001/jama.273.5.402. [DOI] [PubMed] [Google Scholar]
  • 6-3.Pollock ML. Prescribing exercise for fitness adherence. In: Dishman RK, editor. Exercise adherence. Champaign, IL: Human Kinetics Publishers; 1988. pp. 259–277. [Google Scholar]
  • 6-4.American College of Sports Medicine. Guidelines for exercise testing and prescription. 4th ed. Philadelphia, PA: Lea and Febiger; 1991. [Google Scholar]
  • 6-5.Wannamethee G, Shaper AG. Physical activity and stroke in middle aged British men. BMJ. 1992;304:597–601. doi: 10.1136/bmj.304.6827.597. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Different exercise prescription schemes deserve evaluation in United Kingdom

Mark Reeves 1

Editor—Harland et al ably highlight the shortcomings of exercise prescriptions as a means of promoting physical activity as used in the United Kingdom.7-1 The long term adherence of patients who have been prescribed leisure centre type referrals in their study, even in the group with the most intensive intervention coupled with financial incentive, as in other studies7-2 is disappointingly low. It mirrors exactly our experience with our own scheme. The proliferation of such schemes surely results from a combination of good intentions, ease of setting up, and most particularly cost neutrality to the scarce resources of the NHS.

Well documented exercise prescription schemes of a different type being practised in Europe and the United States, often home based, informal, and unsupervised with limited intervention, nevertheless yield good long term outcomes and rates of adherence.7-3 There may subtle cultural reasons why such practice may not easily transfer to the United Kingdom. Yet, given the well established health and social benefits associated with increased physical activity these types of schemes deserve evaluation here before the prescription of exercise is labelled ineffective.

References

  • 7-1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7-2.Taylor AH. Evaluating GP exercise referral schemes: findings from a randomised control study. Eastbourne: University of Brighton; 1996. [Google Scholar]
  • 7-3.Hillsdon M, Thorogood M, Antiss T, Morris J. Randomised controlled trials of physical activity promotion in free living populations: a review. J Epidemiol Community Health. 1995;49:448–453. doi: 10.1136/jech.49.5.448. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

Authors' reply

Jane Harland 1,2,3,4, Martin White 1,2,3,4, Denise Howel 1,2,3,4, Chris Drinkwater 1,2,3,4, David Chinn 1,2,3,4

Editor—The responses to our paper raise important issues requiring clarification. It was necessary to restrict the outcomes reported in the first paper on this study; other outcomes will be reported separately. Some misconceptions arose because we could not describe the intervention in detail in the space allowed. Our scheme was not an exercise prescription scheme.

The motivational interviews aimed to increase inherent motivation for physical activity rather than prescribing specific activities. Participants were encouraged to tailor their activities to suit their personal circumstances: these varied among facility based lifestyle, solitary, and group activities. The aim was to motivate them to do effective (aerobic) activity at least three times per week for at least 20 minutes per session.8-1 Participants were initially encouraged to start any activity and, when ready and if appropriate, to try to increase its frequency and intensity.

The trial was planned as an efficacy (rather than effectiveness) study or evaluation of the experimental stage, with the inherent limitations of such research.8-2 Kerse and Walker and Petrovic et al queried whether our intervention would be feasible and affordable within the resources of the health service. Some misunderstandings may have led correspondents to assume the intervention required more resources than it did. However, refining the intervention so it can be delivered as part of routine primary care is the next logical stage in this programme of research. The results are not generalisable to the population as a whole as mentioned by Petrovic et al, but this was not our aim.

Smith and Sims, Mutrie et al, and Critchley et al commented on the “intervention” received by the control group. We were interested in the effect of motivational interviewing and vouchers over and above the baseline assessment and generally available information so our control group was appropriate for the aims of the trial. Mutrie et al imply that our control group achieved worthwhile increases in physical activity at 12 weeks and one year and suggest that brief interventions may turn out to be the most cost effective way to promote physical activity. This may be so, but our data and those of others show that brief interventions are effective only for a proportion of the population: further attention needs to be paid to the appropriate targeting of brief and more intensive approaches.

We know of no published evidence to support Baker's conjecture that to achieve compliance participants need to go through their exercise programme in mutually supportive groups. This approach is likely to alienate those who are embarrassed at being part of a group, although it may benefit others. Critchley et al suggest an alternative way to address this issue. The nature of our intervention, motivational interview, is, however, quite different from attendance at exercise classes in their study, so the comparison in their table is inappropriate.

Our exclusion criteria reflected the need to exclude patients for whom a submaximal exercise test was unsafe or the results uninterpretable. The exercise test provided physiological measures to validate self reported patterns of activity. In the context of real life, rather than that of an experiment, there would be no need for such a test and no need to exclude such patients.

Mutrie et al state that we used an outdated questionnaire with little known validity to assess physical activity, but that recommended by them was not available at the time of the trial. We accept that questionnaire design has improved since our trial, but the questionnaire we used does not invalidate our results.

Correspondents objected to the headline for This week in the BMJ. The title was too provocative, and we asked the BMJ to modify it before publication, but it was neither totally unjustified nor seriously misleading. Although our trial differs from the popular models of “exercise on prescription” or exercise referral schemes in several ways, the results nevertheless have implications for more typical schemes. Most of these schemes do not address adherence to increased physical activity after the intervention or prescription period (typically 10-12 weeks8-3), and few have evaluated long term changes in physical activity. Because they do not address adherence, schemes that promote only adoption of physical activity are, in the long term, likely to be ineffective and may be considered a waste of scarce resources. We agree with Smith and Sims on the need for further research on methods to maintain increased activity.

References

  • 8-1.Haskell W. Health consequences of physical activity: understanding challenges regarding dose response. Med Sci Sports Exerc. 1994;26:649–660. doi: 10.1249/00005768-199406000-00001. [DOI] [PubMed] [Google Scholar]
  • 8-2.Nutbeam D. Evaluating health promotion—progress, problems and solutions. Health Promotion Int. 1998;13(1):27–44. [Google Scholar]
  • 8-3.Riddoch C, Puig-Ribera A, Cooper A. Effectiveness of physical activity promotion schemes in primary care: a review. London: Health Education Authority; 1998. [Google Scholar]
BMJ. 2000 May 27;320(7247):1470.

National quality assurance framework will guide best value and practice in GP exercise referral schemes

Andrew Craig 1,2,3,4,5, Susie Dinan 1,2,3,4,5, Andrew Smith 1,2,3,4,5, Adrian Taylor 1,2,3,4,5, Nick Webborn 1,2,3,4,5

Editor—As authors of a national quality assurance framework for primary care exercise referral systems, we seek to address some of the confusion surrounding the paper by Harland et al.9-1

In 1998 the British Association of Sport and Exercise Science and what was Exercise England were commissioned by the Department of Health to produce a national quality assurance framework for general practitioner exercise referral schemes in the light of extremely varied practice across the United Kingdom.9-2 The national quality assurance framework now awaits its launch (which will be notified to the BMJ), subject to clarification of who will be the future custodians of a national register of exercise professionals. To ensure best practice and value the national quality assurance framework adopts a whole systems approach in which clear documentation is produced describing selection criteria, screening and assessment procedures, progression, and the training implications for health and exercise professionals.

The paper by Harland et al illustrates the ambiguity of the term exercise prescription scheme. After much consultation with medicolegal advisers we conclude that general practitioners are rarely in a position to prescribe exercise. Instead, referral schemes should entail extending the primary care service to a qualified exercise leader within a carefully developed service agreement. The exercise referral process in the Newcastle project does not seem to match our guidelines, and exercise referral schemes should not be condemned on the basis of this paper.

We must move forward in the professionalisation of physical activity promotion services linked to primary care, given that physical activity is central to health.9-3 Future research reports on the effectiveness of general practice exercise referral schemes should provide sufficient detail to enable readers to judge the intervention in light of the guidelines of the national quality assurance framework.

References

  • 9-1.Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319:828–832. doi: 10.1136/bmj.319.7213.828. . (25 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9-2.Riddoch C, Puig-Ribera A, Cooper A. Effectiveness of physical activity promotion schemes in primary care: a review. London: Health Education Authority; 1998. [Google Scholar]
  • 9-3.Taylor AH. Exercise promotion in primary health care. In: Bull SJ, editor. Adherence issues in exercise and sport. Chichester: Wiley Publishers; 1999. pp. 47–74. [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES