Implications for service provisions

In 2006, NICE commented that there is insufficient evidence for ERS and recommended that the NHS should make ERS available only as part of a controlled trial. Although we have identified four additional trials since the NICE review, there remains very limited support for the potential role of ERS for impacting on PA and, consequently, public health. Arguably, such an uncertain impact provides a case for the disinvestment in ERS. However, we found little evidence of how the ERS intervention sought to develop a sustainable active lifestyle in participants, as recommended in the NHS NQAF. Although ERS programmes in our review aimed to increase medium- to long-term PA, they were typically based on only a 10- to 12-week leisure centre-based period intervention. With the exception of one trial (by Jolly et al.⁶⁸), there was minimal reference to health behaviour change techniques and theories that typically underpin interventions to promote an increase in daily PA.

Suggested research priorities^*

In 2006, NICE³⁵ recommended that ERS should only be part of controlled research studies in order to better determine its clinical effectiveness and cost-effectiveness. Sowden and Raine³³ argue that (formal) evaluation of ERS is no longer a realistic possibility, due to the comprehensive coverage of schemes, widespread assumptions of effectiveness, likely difficulties in obtaining research funding, and indirect adverse consequences of dismantling schemes. Although this may potentially be the case for sedentary populations, there is still scope for an evidence base in diagnostic populations.

Although we have shown that additional RCT evidence has been produced since NICE made its recommendations, we have identified a number of gaps in the evidence base for ERS, some of which may require further trial-based evaluations:

• RCTs assessing the effectiveness and cost-effectiveness of ERS in disease groups that might benefit from PA. In addition, RCTs should seek to incorporate hard-to-reach populations (e.g. ethnic minorities) that are traditionally not represented in trials.
• Such RCTs should be better reported, include long-term data on the effectiveness of ERS and the sustainability of PA change, incorporate objective measures of PA (e.g. accelerometers) and health outcomes (e.g. blood pressure, serum lipids) and incorporate parallel process evaluations to better understand the mediators and barriers to behaviour change.
• Exercise referral scheme programmes vary in their procedures and this may impact on uptake and adherence. Future trials should therefore be designed to better understand the contribution of different programme components (e.g. level of staff training) to the effectiveness and cost-effectiveness of ERS.
• Head-to-head RCTs comparing the effectiveness and cost-effectiveness of different models of primary-care interventions aimed at promoting PA.
• Further quantitative and qualitative studies are needed to determine the moderators of uptake and adherence to ERS.
• Theory-driven interventions should be developed to complement ERS to foster long-term change in PA, and evaluated to enhance our understanding of mediators and processes of behaviour change (e.g. SDT, motivational interviewing).
• The development of improved approaches to modelling the cost-effectiveness of ERS, capturing the potential impact on a wide range of health outcomes.

Footnotes

*

Note: While undertaking this report we became aware of a large ongoing cluster randomised trial of ERS funded by the Welsh Assembly Government.¹⁵⁵ A total of 2160 sedentary adult men and women with CHD risk factors and/or mild-to-moderate depression, anxiety or stress from 12 local health boards in Wales, referred directly by health professionals working in a range of health-care settings, were randomised either to a 16-week tailored exercise programme run by qualified exercise professionals at community sports centres (intervention) or to receive an information booklet on PA (usual care control). Despite contacting the authors, we were unable to obtain outcome data from this study to allow its incorporation into our analyses. This trial has now been completed and a brief report has recently been made publicly available.¹⁵⁶ The trial findings appear to be very consistent with those of this report. Compared with control, a small increase in the primary outcome of PA (7-Day Physical Activity Recall Questionnaire) with ERS at 12 months' follow-up (OR 1.19, 95% CI 0.99 to 1.43) was seen. Based on a trial-based economic evaluation and using EQ-5D and cost data collected in the trial, an ICER of £12,111/QALY was reported.