Kickstart patient movement: a 5-step framework for primary care clinicians to support inactive patients in becoming more active

Abstract

Physical activity (PA) is a cornerstone of both disease prevention and long-term condition management, yet it remains absent from many treatment plans, particularly in primary care. Despite clinicians recognising the value of PA, systemic barriers such as time constraints and limited training hinder its integration into everyday consultations. For this reason, there has been a call for further resources to improve clinician confidence in initiating these conversations. This viewpoint presents a practical, five-step framework to help primary care clinicians support inactive patients to become more active. It does this by integrating core principles of PA counselling, including motivational interviewing, risk screening and the frequency, intensity, time and type (FITT) principle into a practical, accessible framework. It simplifies the often fragmented guidance on PA prescription, offering clinicians a clear, time-efficient tool to support behaviour change in routine practice. A visual infographic translates the five steps into an accessible aid for busy consultations. This viewpoint aims to equip primary care clinicians with the clarity and confidence needed to embed PA advice into their routine care. In doing so, it supports the shift towards proactive, personalised and preventive healthcare.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Physical activity (PA) is a proven method for preventing and managing chronic disease, yet it remains underused in clinical practice. Many primary care clinicians recognise its importance but feel insufficiently trained and lack practical resources to facilitate meaningful conversations with patients.

WHAT THIS STUDY ADDS

• This article introduces a straightforward five-step framework to help primary care clinicians confidently support inactive patients. It promotes a shift from directive prescribing to collaborative goal-setting and offers clear guidance on safe screening. A visual infographic acts as a quick reference during consultations.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The framework provides a foundation for future research on implementing brief PA interventions in routine care. It also emphasises the importance of assessing long-term patient outcomes and the effectiveness of clinician training in PA promotion.

Introduction

Physical activity (PA) offers major health benefits, including the prevention and management of chronic diseases.¹ Around 5 million global deaths annually are attributed to physical inactivity. In the UK, it contributes to one in six deaths, which is equivalent to smoking.² Of equal importance, it is estimated that 40% of long-term conditions could be prevented if the population successfully met the UK Chief Medical Officer’s PA recommendations.³ The evidence is clear: getting the nation moving is a public health imperative. In the UK Government’s green paper on preventing ill health, the 2020s were hailed as the era of ‘proactive, predictive, and personalised prevention’. Fast forward to 2025, and yet exercise is still absent from many treatment plans, and global PA levels have stagnated.⁴ A key barrier appears to be the perceived lack of clinician knowledge or confidence in initiating conversations about PA and cocreating tailored plans with patients based on their individual circumstances and variables.^{5 6} Indeed, more than 50% of UK-based primary care physicians have previously reported they had not undertaken any training in PA counselling or advice.⁷ Effective guidance must consider a range of individual factors, including current and past activity levels, relevant comorbidities, personal preferences, motivations and barriers. As a result, tailored exercise advice often gets sidelined, and patients miss out on its powerful benefits. That needs to change. Previous research exploring primary care clinicians’ perspectives on promoting PA has identified that having a clear structure and greater confidence in PA-related discussions can play a crucial role in overcoming many of the structural and logistical barriers they face.⁸

Therefore, this viewpoint presents a practical, five-step framework, grounded in research and real-world experience, to help healthcare professionals confidently support inactive patients in becoming more physically active. It does this by integrating core principles of PA counselling, including motivational interviewing, risk screening and the frequency, intensity, time and type (FITT) principle into a practical, accessible framework. It simplifies the often fragmented guidance on PA prescription, offering clinicians a clear, time-efficient tool to support behaviour change in routine practice. A visual infographic (figure 1) translates the five steps into an accessible aid for busy consultations. This viewpoint aims to equip primary care clinicians with the clarity and confidence needed to embed PA advice into their routine care. In doing so, it supports the shift towards proactive, personalised and preventive healthcare.

Figure 1. Infographic outlining a five-step framework to guide primary care clinicians in supporting inactive patients to increase their physical activity levels. PA, physical activity.

Step 1: assess the patient’s readiness to change and current PA levels

Before making suggestions for change, clinicians should identify an individual’s motivations and barriers to PA and use this insight to guide collaborative decision-making about their future PA plans. This approach is supported by the emergence of motivational interviewing as an essential component of conversations regarding PA, helping healthcare professionals engage patients in meaningful conversations about behaviour change. A simple way to initiate a conversation and assess a patient’s readiness for PA is to ask them to rate their readiness on a scale from 0 to 10, where 0 means ‘not at all ready’ and 10 means ‘completely ready’. This is useful for several reasons. First, it quickly identifies the patient’s stage of change, which will shape the rest of the conversation. It also paves the way for deeper questions that reveal existing motivations and strengths, while fostering forward thinking and collaborative problem-solving. Rather than telling patients what to do, supporting them in exploring their motivations and barriers fosters autonomy and adherence to tailored PA plans. We therefore advocate against an approach regimented by a rigid PA prescription, as this is less likely to lead to sustained improvements in PA levels.

Clinicians should then gauge the patient’s current level of structured and unstructured PA, including the relevant proportions of moderate and vigorous activities. This baseline understanding forms the foundation for personalised recommendations, as conversations with largely inactive individuals will differ significantly from those already engaging in regular PA.

PA levels can be quickly gauged using two questions:

1. ‘How many days per week do you engage in moderate or vigorous intensity PA?’

2. ‘During these days, how many minutes of moderate or vigorous intensity PA do you do?’

Moderate and vigorous activities can be graded using the ‘Talk-Sing Test’. Clinicians should explain that during moderate PA, they should be able to talk but not sing. Likewise, during vigorous PA, you should have difficulty talking more than a few single words in response to any questions. It is also becoming increasingly common for individuals to have access to smartwatches that track their heart rate during activity and estimate their maximum heart rate (HR_max). Moderate PA can be more objectively described as activity that results in an HR of 60%–75% of their HR_max, while vigorous activity is activity that results in an HR of 75%–90% of their HR_max. To estimate the maximum age-related heart rate, subtract the patient’s age from 220. For example, for a 40-year-old person, the estimated maximum age-related heart rate would be calculated as 220–40 years=180 beats per minute.⁹ It is also important to ask follow-up questions that uncover forms of ‘hidden’ PA, such as that achieved during travel, work and household chores. These everyday movements often go unnoticed, yet they play a meaningful role in energy expenditure and can form the foundation for increasing structured activity over time. By highlighting and validating these efforts, clinicians can help patients reframe their perception of what ‘counts’ as PA. This not only boosts self-efficacy and motivation but also creates a more positive, strengths-based starting point for setting achievable and sustainable goals.

Step 2: screen for relevant risk factors and contraindications

Clinicians often hesitate to prescribe PA to individuals who may be at increased risk of adverse health events related to PA. This uncertainty, often stemming from limited knowledge, can create a barrier to promoting PA and may lead to unnecessary referrals to secondary care for medical clearance before starting a PA programme. While vigorous-intensity PA carries a small but measurable acute risk of cardiovascular complications, it remains essential to minimise this risk in susceptible individuals.¹⁰ However, this concern should not deter clinicians from recommending PA, as the long-term benefits far outweigh the short-term risks.¹¹ Tackling individual fears around adverse events can empower healthcare professionals to drive meaningful behaviour change in everyday practice. Current evidence does not support the routine use of preparticipation medical clearance for individuals with stable long-term conditions, provided they increase their PA levels gradually from their current baseline.¹² Supporting this, recent landmark studies have demonstrated that higher levels of leisure-time PA are linked to a reduced risk of mortality, even among individuals with elevated coronary artery calcification (CAC)¹³ and that high and very high volumes of PA were not associated with the progression of CAC over time.¹⁴

There are several risk factors that the clinician should ascertain to ensure that any recommendations made to the patient are safe:

• Existing diagnosis of key medical conditions, especially cardiovascular, metabolic or renal diseases.

• Signs or symptoms of cardiovascular, metabolic or renal diseases.

• Family history of sudden cardiac death or congenital heart disease.

• Medications.

It is useful for clinicians to refer to the American College of Sports Medicine (ACSM) list of relative and absolute contraindications to PA. With these factors in mind, the ACSM preparticipation guidelines can help identify individuals who are safe to begin PA at a given intensity, as well as those who may need referral for further testing (such as cardiopulmonary exercise testing), supervised exercise programmes or a more gradual progression in activity intensity.^{15 16}

Step 3: use key principles to agree on a tailored programme

We recommend several key principles when it comes to agreeing on a PA plan with the patient. The information previously ascertained in steps 1 and 2 regarding the individual’s motivations, preferences and perceived barriers to PA is crucial when cocreating a personalised plan. This ensures that any recommendations made by the clinician support the patient’s values and readiness for change. Naturally, the recommendations given to a highly motivated patient will differ significantly from those offered to someone still in the precontemplation or contemplation stages of behaviour change.

First, begin with the individual’s current level of PA and gradually increase exercise intensity and duration over time, avoiding sudden or unfamiliar vigorous activity.

PA recommendations must be individualised, realistic and incorporate patients’ preferences to enhance adherence. Second, using the FITT principle—frequency, intensity, time and type—allows clinicians to tailor PA to an individual’s specific needs, preferences and medical conditions. By structuring activity in measurable terms, the FITT framework also makes it easier to monitor progress and adjust the plan over time to optimise health benefits. For individuals who feel more ambivalent, apply the FITT principle as a flexible framework in a shared decision-making conversation, supporting them in shaping the details around what feels realistic and personally meaningful. For example, clinicians might suggest starting with brief, manageable bouts of movement, such as a 5–10 min brisk walk per day, as a non-intimidating entry point. Framing these as small, achievable wins can help build confidence and a sense of progress while maintaining a collaborative and non-judgmental tone. Leveraging local PA initiatives, such as the Healthwise Scheme, NHS-recommended resources or beginner-friendly YouTube videos, can provide accessible and supportive entry points for individuals at the start of their PA journey, especially those who may feel unsure about where to begin.¹⁷

The ultimate goal is to support individuals in maintaining PA levels that align with WHO recommendations, incorporating a mix of aerobic activity alongside exercises that build strength, balance and coordination for a well-rounded, sustainable routine.¹⁸

Third, at this stage, it is also important to guide the patient on how to recognise unstable or concerning symptoms, and when it is appropriate to seek medical attention.

Step 4: give advice to reduce sedentary behaviour

Reducing sedentary behaviour is crucial, as prolonged sitting is independently associated with increased risks of cardiovascular disease, type 2 diabetes and all-cause mortality, even in individuals who meet PA guidelines.¹⁹ Clinicians should encourage patients to integrate small, manageable changes into their daily routines to help reduce sedentary time. This can span all aspects of daily life, including work, commuting, household tasks and leisure activities. Clinicians might consider offering the following examples to help patients incorporate more activity into their daily lives:

• Encourage replacing sedentary travel by car, bus or taxi with active modes such as walking or cycling.

• Consider where meetings can be done standing or walking.

• Consider breaking up or reducing sedentary screen time, both during and outside working hours.

• Encourage increasing daily step count through simple measures that can be incorporated into the individual’s routine, for example, taking the stairs.

Step 5: arrange a follow-up consultation

A follow-up consultation is vital to monitor progress, address any challenges, assess for warning symptoms and adjust the exercise prescription as needed. Reinforce motivation by revisiting the patient’s personal goals and using positive encouragement. If you are unable to provide follow-up yourself, consider signposting or referring the individual to an appropriate NHS service, such as social prescribing link workers, physiotherapy, or community-based PA programmes, who may be better placed to offer ongoing support.

Conclusion

In conclusion, PA should be seen as a core component in the prevention and management of chronic conditions, yet it remains underused in clinical practice. With growing calls for personalised, preventive care, primary care clinicians are ideally placed to champion movement as medicine. However, to do so confidently and effectively, they need a simple, practical framework that integrates evidence with real-world realities. With experience, clinicians will develop their own structure for addressing these conversations. The five-step approach outlined aims to empower healthcare professionals to assess readiness, screen safely and cocreate meaningful, tailored plans that reflect the patient’s context, goals and capacity for change. To support implementation, the infographic can be embedded into electronic health record systems as a quick-reference visual aid and linked to templates for health checks, chronic disease reviews or lifestyle counselling. Clinicians seeking further training can access online resources such as Moving Medicine, developed by the Faculty of Sport and Exercise Medicine UK. This key platform offers free, evidence-based tools, including condition-specific consultation pathways and the Active Conversations course, which focuses on motivational interviewing and behaviour change, as highlighted in step 1 of our framework.²⁰ Small changes in how we approach conversations around PA can lead to significant improvements in patient outcomes. By embedding PA as a routine part of clinical care, we can shift from reactive treatment to proactive health promotion.