Physical Activity: Brief Advice for Adults in Primary Care

Objectives

Promote health and wellbeing among inactive adults aged 19 and over by increasing physical activity towards UK recommendations on type, intensity and duration, while encouraging adults already meeting the recommendations to maintain their activity levels.[1][2]The guidance seeks to make assessment of physical activity and delivery of brief advice a routine component of primary care and wider health promotion.[3][4]

• Prevent and help manage coronary heart disease, stroke, type 2 diabetes, some cancers, mental health problems and musculoskeletal conditions through greater physical activity, alongside benefits for mood, relaxation, stress reduction, mortality and life expectancy.[1][5]
• Identify adults not meeting physical activity guidance and provide tailored, motivating brief advice, ranging from concise verbal encouragement to a more extended, individually focused discussion with written materials, support or follow-up where appropriate.[3][1]
• Integrate physical-activity assessment, advice and follow-up into relevant care pathways, long-term-condition management and services for groups more likely to be inactive.[2]
• Address inequalities in physical activity associated with age, gender, ethnicity, socioeconomic status and disability, including unequal access to safe, suitable and accessible opportunities in deprived areas.[5][4]
• Ensure that physical activity promotion is embedded in wider national and local strategies that tackle barriers to active lifestyles and expand locally available opportunities for activity.[3][6]
• Strengthen practitioner capability through information and training on activity guidelines, assessment, misconceptions, local signposting and brief advice.[5]

Implementation

Deliver brief physical-activity advice principally through routine primary care contacts, using a person-centred model that assesses activity, tailors support and connects people to appropriate local opportunities.[1][2]Implementation depends on commissioners, providers, practitioners, local authorities and public-health systems creating the infrastructure, workforce capability and accessible activity options needed for advice to lead to sustained participation.[7][6]

• Assess activity during consultations, waiting periods or planned sessions for long-term-condition management, using professional judgement and validated tools such as the General Practice Physical Activity Questionnaire rather than visual impressions.[1][6]
• Enable general practitioners, nurses, health visitors, pharmacists, physiotherapists, midwives, health trainers, exercise professionals and mental health professionals to identify inactive adults and deliver or arrange brief advice.[1]
• Tailor conversations to each person’s motivations, goals, ability, health status, disability, circumstances, preferences and barriers, and involve families, carers or guardians where appropriate.[7][2]
• Provide information on suitable local opportunities, including non-sporting activities and disability-accessible facilities, resources and leisure services.[2][4]
• Use very brief, repeatable informal advice where consultation time is limited, alongside motivational interviewing and the Department of Health’s Let’s Get Moving physical activity care pathway where applicable.[6][4]
• Establish operational support through Read Codes, standard documents and forms, current information on local provision, and processes to record and follow up advice.[2]
• Follow up at a later contact by discussing activity undertaken and progress towards personal goals or the UK recommendations.[2]
• Incorporate physical-activity assessment and advice into commissioning, relevant quality and outcomes framework indicators, public-health outcomes work and local long-term disease-management strategies.[2][6]
• Address delivery barriers including competing demands on primary care time, workload, limited knowledge or confidence, attitudes, unclear professional remit, inadequate support materials and perceived insufficient incentives.[8][9][10]
• Train practitioners and improve their confidence, knowledge and awareness of their responsibility for physical-activity promotion, as these factors influence whether advice is offered.[9][11]
• Support patient understanding, recall and awareness of activity recommendations, which are associated with receptiveness and willingness to act on advice.[11][12]

Governance and evidence development were led by the National Institute for Health and Care Excellence through its Public Health Interventions Advisory Committee, supported by multidisciplinary members, external evidence-review contractors and a project team providing analytical, health-economic, editorial and coordination functions.[13][14]The committee considered effectiveness, cost effectiveness, inequalities, equality and diversity, ethics, harms, benefits, applicability and ease of implementation when developing recommendations.[15]

Brief advice has a modest but consistent effect on physical activity, although evidence is insufficient to establish whether outcomes differ by advice duration, content or professional delivering it.[4]Evidence also supports a cost-effective assessment relative to usual care, with an incremental cost-effectiveness ratio of £1,730 and a modelled 99.9% probability of cost effectiveness at a £20,000 value per additional quality-adjusted life year.[16]The source does not specify a programme budget, funding allocation, quantified funding gap or resource-mobilisation plan.[16]

Monitoring & Evaluation

Monitoring centres on identifying inactive adults, recording assessment and advice, and following up progress, while the broader evidence programme assesses effectiveness, equity, delivery systems and cost effectiveness.[1][2][17]

• Assess physical activity in primary care using professional judgement and validated tools, including the General Practice Physical Activity Questionnaire, rather than visual cues.[1][6]
• Record physical-activity assessment outcomes and brief-advice discussions, using Read Codes where appropriate, and maintain systems, forms and standard documents to support recording.[1][2]
• Follow up at later appointments or other opportunities by discussing activity undertaken and progress towards personal goals or the United Kingdom physical activity guidelines.[2]
• Align assessment and advice with domain 2 of the Public Health Outcomes Framework indicator on physically active and inactive adults, and raise awareness of relevant Quality and Outcomes Framework indicators, including hypertension indicators HYP004 and HYP005.[2][6]
• Use the Let’s Get Moving care pathway and the General Practice Physical Activity Questionnaire to assess patients’ activity levels.[6]

The evidence indicates that brief advice has a modest but consistent effect on physical activity, and moderate evidence from 15 studies suggests that people receiving brief advice, or consulting trained primary care professionals, report higher activity levels.[4][18]However, evidence is insufficient to establish whether outcomes vary by advice duration, content or professional delivering it.[4]

• Evaluate effectiveness and cost effectiveness by examining advice duration and frequency, practitioner type and training, tailoring for population groups, and the use of guidance and supporting systems.[17]
• Measure physical activity objectively as well as through self-reporting where possible, and assess mental wellbeing alongside possible harmful or negative effects.[17]
• Investigate routine use of the care pathway and questionnaire, barriers to questionnaire use, and infrastructure or incentive arrangements that increase assessment and advice.[17]
• Assess barriers, facilitators, differential effects across population groups, incentives, follow-up, behaviour-change maintenance and implementation of earlier recommendations.[13]

Formal implementation reporting, surveillance schedules and a comprehensive accountability framework are not specified in the supplied material.[1][2][13]Accountability for implementation is principally associated with primary care practitioners, commissioners and the Public Health Interventions Advisory Committee, which reviews evidence and develops public-health recommendations.[1][2][13]

Evidence governance includes documented review findings in evidence tables and statements, methodological quality appraisal, applicability judgements, economic modelling and committee consideration of effectiveness, inequalities, ethics, harms, benefits and implementation feasibility.[19][15]The guideline was updated in August 2020 to reflect the 2019 United Kingdom Chief Medical Officers’ physical activity recommendations.[20]

Costing & Financing

No programme budget, dedicated funding allocation, funding gap, resource-mobilisation plan or implementation cost is specified.[1][2][16]The material nevertheless identifies operational resource needs, including practitioner training, standard documentation, coding and recording systems, current information on local opportunities, printed materials, accessible facilities and potential incentives.[2][8][9]

• Recognise that physical inactivity is estimated to cost the National Health Service £1.06 billion for coronary heart disease, stroke, diabetes, colorectal cancer and breast cancer, an estimate described as conservative because other affected conditions are excluded.[5]
• Recognise wider estimated annual costs of £5.5 billion from sickness absence and £1 billion from premature deaths among working-age people from lifestyle-related diseases.[6]
• Note that the estimated average cost of physical inactivity was £5 million per primary care trust in England in 2008.[6]
• Use economic evaluation findings indicating an incremental cost-effectiveness ratio of £1,730 for brief advice compared with usual care.[17][16]
• Interpret the model from a lifetime National Health Service and Personal Social Service perspective, using quality-adjusted life years as a principal outcome.[15][16]
• Note that probabilistic sensitivity analysis estimated a 99.9% probability that brief advice would be cost effective at a value of £20,000 per additional quality-adjusted life year.[16]

The economic evidence comprised reviews of economic evaluations and modelling, including sensitivity and cost-consequence analyses.[19][15]Brief physical-activity advice in primary care was judged cost effective, although the underlying effectiveness evidence was characterised as weak or limited and uncertainty was not fully explored.[10][16]

Local implementation should be considered alongside funding priorities, service-development priorities, equality duties and health inequalities, but no monetary valuation of these requirements is provided.[7][2]