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Hertfordshire

Exercise Referral Scheme:

Quality Operating Standards

July 2016

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Executive Summary

The purpose of this document is to provide a set of quality operating standards for referring healthcare professionals, exercise professionals and scheme coordinators. It also formally documents the roles and responsibilities of the referring healthcare professionals and the exercise professionals delivering the scheme to patients. The standards are to ensure there is consistent quality in the referral process, delivery and evaluation of the scheme across Hertfordshire in line with The National Institute for Health and Care Excellence (NICE) guidance on exercise referral and behaviour change. Referring healthcare professionals will make a referral on to the scheme by using the referral scheme patient pathway, ensuring patients meet the patient eligibility criteria, and completing the scheme referral form. Healthcare professionals should ensure that the patient’s medical history is complete and correct to the best of their knowledge at the time of referral and must complete the healthcare professional declaration the referral form. The patient is responsible for contacting the leisure facility to book their initial assessment/ induction. They will also be responsible for taking their referral form directly to their preferred Hertfordshire Exercise Referral Scheme accredited leisure facility. After the patient has been screened by the exercise professional (trained in Level 3 Exercise Referral) and accepted onto the scheme, they will jointly develop an agreed activity plan. The plan will consist of activities the patient can participate in both inside and outside the leisure facility (e.g. walking).

Support will be offered to the patient by the exercise professional over a minimum of a 12 week period, in which time the patient will undergo a number of review sessions* to ensure their activity goals are being met. During contact time with the patient the exercise professional will use evidence based behaviour change techniques to help foster long term adherence to a more active lifestyle.

On exit from the scheme patients will be encouraged to remain physically active by the exercise professional. They will be signposted to a variety of activity opportunities including membership options and casual usage of the leisure facility, health walks, community based physical activity initiatives, independent activity such as walking and using the Health in Herts ‘Keep Active’ web pages.

The scheme will be monitored and evaluated regularly to ensure it is being utilised, it is maintaining the scheme quality standards and patients accessing the scheme are achieving positive outcomes. Scheme evaluation will follow the NICE recommended Standard Evaluation Framework (SEF) for physical activity interventions so will include reporting patient’s demographics, referral source, referral medical condition, completion rates and changes in physical activity. *Review and exit sessions typically at week 4, week 8 and week 12 (exit), however timescales may be subject to district/borough variation.

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Contents Table:

Description Page

Introduction 4-5

Aims 5

Objectives 5

Patient Eligibility Criteria 7

Scheme Patient Pathway 8

Healthcare Professionals Eligible to Refer 9

Healthcare Professional’s Checklist 9

Duration of Scheme 10

Scheme Pricing 10

Leisure Operator’s Checklist 11-12

Risk Stratification Tool 13-14

Patient’s Responsibilities 15

Patient’s Safety 15

Monitoring and Evaluation 16-17

Key Stakeholders: Roles and Responsibilities 17

Summary 18

Appendices:

APPENDIX 1 Hertfordshire Exercise Referral Scheme Delivery Facilities

19-21

APPENDIX 2: Council Contacts 22

APPENDIX 3: Summary of NICE Guidance on Exercise Referral 23-24

APPENDIX 4: Scheme Forms and Checklists Summary 25

Form 1: Referral Form 26

Form 2: Scheme Patient Information Sheet 27-28

Form 3: PARQ 29

Form 4: Checklist for Exercise Referral Consultation with Exercise Professional

30

Form 5: Lifestyle Assessment 31-32

Form 6: Initial Physical Activity Assessment 33

Form 7: 4 and 8 Week Review 34

Form 8: 12 Week Exit Review 35

Form 9: Scheme Appraisal Questionnaire 36

Form 10: Physical Activity Clearance / Change in Health Form 37-38

Form 11: Case Study Template 39-40

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Introduction:

Participation in physical activity is a cost-effective way to improve health, it can help to prevent and manage over 20 chronic conditions including coronary heart disease, some cancers, diabetes, musculoskeletal disorders, mild to moderate depression and obesity. Having a physically active population can help reduce costs to the NHS and wider society. The latest data indicates that 25% of the adult population in Hertfordshire report being inactive. Physical inactivity is costing the health economy in the county more than £16 million per year, excluding the cost of inactivity related to obesity and mental health conditions. In Hertfordshire the countywide multi-agency Health and Physical Activity Work Group has a strategic aim to “Implement and develop effective practice linked to healthcare”, specifically under this aim in the action plan there is a task to “Unify all Exercise on Referral schemes, under an agreed set of protocols across the county”. It is with this mandate plus endorsement from the districts/boroughs, leisure operators and the two CCGs that these quality operating standards for exercise referral in Hertfordshire have been developed. To ensure the Hertfordshire exercise referral scheme operates to a set standard, has robust monitoring/evaluation and maintains patient safety. Prior to these operating standards there were schemes in place across all 10 districts/boroughs however there were a number key challenges they faced:

Protocols, referral forms and patient inclusion/exclusion criteria varied between schemes.

Monitoring and evaluation / data collection and reporting was inconsistent and in did not meet NICE guidelines.

Schemes were not used at scale by NHS health professionals who could refer.

Most schemes lacked of post intervention follow up evaluation.

Patients could only access the scheme in the district/borough their GP surgery was located.

Improvements to the existing schemes protocols have been made and brought together in this document for a consistent, quality assured scheme which can be evaluated. The countywide scheme has a number of key features:

It operates across all 10 districts/boroughs in Hertfordshire.

Is open to patients aged 16+ years, registered to a GP practice in Hertfordshire, and who fulfil the referral criteria.

Referral criteria and forms are standardised.

Patients can chose which participating facility they wish to access within the county once referred.

Universal quality standards are in place for leisure operators to follow.

Patients have access to the scheme for a minimum of 12 weeks for support in becoming more active at their delivery site of choice.

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Patients will be given a tailored physical activity programme and receive support, motivation and monitoring by the exercise professionals delivering the scheme.

Patients will be offered a range of options to remain active once they exit.

The scheme will be regularly monitored and evaluated in line with NICE guidelines, with the findings shared with key stakeholders.

NICE guidance (PH54) 2014 considered exercise referral schemes that try to increase physical activity which focussed on:

People who are sedentary or inactive.

People who have an existing health condition (for example, coronary heart disease, diabetes or depression).

People who have other risk factors for disease, such as being overweight or obese, having raised blood pressure or cholesterol levels, or experiencing mild depression, anxiety or stress.

Schemes typically involve referral of patients from healthcare professionals to exercise professionals (trained in a Level 3 Exercise Referral qualification). Patients are supported through an exercise programme often over a 12 week or more period. Schemes for rehabilitation including cancer, cardiac or pulmonary rehabilitation programmes are excluded from this scheme.

The National Institute for Health and Care Excellence (NICE) have produced guidance on exercise referral schemes and this is summarised in appendix 3 of these quality operating standards.

Schemes are widespread across the country; NICE noted that many of those involved in commissioning, developing and delivering exercise referral schemes believe they are an effective use of public money. However they also suggest the evidence on the effectiveness of referral schemes is limited; therefore robust evaluation of schemes is essential to demonstrate their effectiveness. There are some examples of good practice where schemes have been independently evaluated and shown to be effective, for example the Welsh National Exercise Referral Scheme. This document aims to outline the operating procedures for the countywide exercise referral scheme. They cover the processes and standards for the referral, delivery and evaluation of the scheme. These standards are based on the NICE guidelines for exercise referral schemes and the British Heart Foundation (BHF) Toolkit for Exercise Referral. They have been developed in partnership with the local authorities in Hertfordshire, leisure operators and the clinical commissioning groups (CCGs).

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Scheme Aims:

To improve the health of the residents in Hertfordshire.

To promote the benefits of an active healthy lifestyle.

To have a good quality exercise referral scheme which is consistent across the county and has clear roles and responsibilities for those referring into and delivering the scheme.

Scheme Objectives:

To unify all Exercise on Referral schemes, under an agreed set of quality operating standards across the county.

To standardise referral criteria, referral forms, operating procedures and evaluation of schemes across the county.

To increase patients physical activity levels towards achieving the Chief Medical Officers recommendations of 150 minutes of moderate intensity physical activity per week.

To increase the accessibility and attraction of the local leisure services to the residents of Hertfordshire.

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Patient Eligibility Criteria: The patient eligibility criteria have been devised based on the BHF Exercise Referral Toolkit to follow best practice and ensure patient safety. To meet the criteria patients must be:

Adults aged 16+ years.

Registered with a general practice in Hertfordshire.

Meet at least one of the clinical Inclusion referral criteria listed below.

Sufficiently motivated to want to increase their physical activity levels. AND

Be Inactive (not currently meeting the Chief Medical Officer's recommendation for physical activity of 150 minutes a week).

Inclusion Criteria Exclusion Criteria

Over 16 years of age Under 16 years of age

Motivated to becoming more active Febrile Illness

High total cholesterol levels (consistently > 5.2 mmol/L)

Latest Blood Pressure either:

Systolic: >180mmHg or

Diastolic: >100mmHg

Unhealthy weight (BMI > 24.9 kg/m²)

Diabetes - Uncontrolled

Hypertension - Controlled

Severe or poorly controlled asthma

Diabetes - Controlled COPD - Severe

Suffer from mild to moderate rheumatoid arthritis or osteoarthritis

Stroke/TIA - Recent (<3 months ago)

Has low back weakness and inflexibility

Peripheral vascular disease

Asthma - Controlled Unstable or severe mental health state

Patients requiring musculoskeletal rehabilitation

Resting heart rate > 100 BPM

Suffer from mild to moderate mental health condition

Established ischaemic heart disease

COPD - Mild to moderate Unstable or acute heart failure

Osteoporosis Aortic valve stenosis

Stroke/TIA - >1 year ago. Stable CV symptoms. Mobile with no assistance required

Unstable angina

Uncontrolled atrial or ventricular arrhythmias

Inactive- an individual who is not physically active for a total of 30 minutes more than twice a week

Active - an individual who is already physically active for a total of 30 minutes more than twice a week

Patients who in healthcare professional’s opinion are not medically fit to undertake a physical activity programme

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Hertfordshire Exercise Referral

Scheme Patient Pathway

Patient’s

GP**

Exercise Referral

Professional**

Exchange of information

about changes in

patient’s health

Healthcare Professional - Identify patient who meets

referral criteria and is motivated to take part in the scheme

Healthcare Professional - Completes Exercise Referral

form and issues it to the patient with scheme patient information sheet to take to the initial consultation

Patient (paper referral) - Phones

participating leisure facility of choice to arrange initial consultation

Initial Consultation with Exercise Professional - Referral form review - PARQ screening - Lifestyle assessment - Initial assessment - Develop physical activity plan - Facility induction - Set dates for review sessions* - Signpost community activities

Review* Consultations with Exercise Professional - Progress review - Review assessment - Revise physical activity plan - Set dates for reviews*

Exit Review* with Exercise Professional - Progress review - Final assessment - Explore exit routes - Patient completes scheme

feedback form / case study

Exit Routes Examples - Leisure Facility user - Community based activity - Health Walks - Active Transport (walk/cycle) - Independent Activity + Sport - Everyday Activity (e.g. DIY)

*Review and exit sessions typically at week 4, week 8 and week 12 (exit), however timescales maybe subject to district/borough variation. ** Information should be exchanged between GP and Exercise Referral Professional if either observes deterioration in patent’s health whilst participating on the scheme.

Leisure Operator (online referral) - Leisure facility

phones patient to arrange initial consultation

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Healthcare Professionals Eligible to Refer: The following healthcare professionals, working in Hertfordshire are able to refer patients into the scheme, having read and understood the quality operating standards:

General Practitioners (GPs)

Practice/ Community/ District Nurses

Hospital Consultants, Doctors and Nurses

Healthcare Assistants

Health Visitors

Community Pharmacists

Physiotherapists

Osteopaths

Occupational Therapists

Mental Health Professionals

Cardiac and Pulmonary Rehabilitation Professionals

Dieticians

Healthcare Professional’s Checklist: These quality standards aim to make the process of healthcare professionals referring patients as quick and easy as possible. To access the scheme patients must be referred by a healthcare professional using the referral form in appendix 4. Self-referrals by patients is not permitted as exercise referral requires the transfer of relevant medical information about an individual in order for an exercise professional to develop a tailored physical activity programme and ensure patient safety. This follows national best practice guidance on exercise referral from the BHF.

Check the patient meets the scheme patient eligibility criteria and has not presented any contra-indications to exercise.

Conduct a physical activity brief intervention with the patient.

Assess patient’s readiness to change.

Fully complete either the paper or online (where available) referral form to ensure transfer of accurate patient details to the exercise professional. Inform the patient on how to use their referral and give them the scheme patient information sheet. (see appendix 4)

If/when issued, to review and complete the physical activity clearance/ change in health form and return to the exercise professional.

Notify the leisure venue/ exercise professional of any relevant change in health of their referred patient.

Wherever possible flag the patient’s record for follow up to see if they have taken up the referral and increased their physical activity levels.

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Duration of Scheme: Each patient has access to the scheme for the minimum duration of 12 weeks; commencing with an initial consultation/ induction, followed by review sessions at week 4, week 8 (preferably) and on exit. During this time, the patient is able to participate in physical activity as regularly as they wish, subject to payment of the local payment tariff if applicable for example when accessing a leisure facility.

Scheme Pricing: Patients are required to self-fund to participate on the scheme; there is no payment to the healthcare professional making the referral. Referred patients who attend the initial physical activity consultation and require GP clearance to commence or resume a physical activity programme will not be charged by the GP practice for completing the physical activity clearance/ change in health form. Each district/borough in Hertfordshire has a set “pay as you go” and/or a monthly direct debit price payable by the patient, for latest price tariffs please contact your local participating leisure venues. Access is available for gym/swim sessions; access to classes is dependent of each leisure venue and subject to availability. The per session fee is also applicable for the consultation and review sessions; however, the patient is entitled to use the facility before or after their consultation or review at no additional cost. As a principle the fees patients pay should be as low as practically possible to promote access to all and remove cost as a possible barrier to participation. On exit from the scheme patients should be offered reduced rate membership to use the leisure facility to encourage ongoing adherence to a more active lifestyle. The cost of participation in any ‘community’ activity outside of the leisure venue will met by the patient, and it is the patient’s choice whether or not they choose to access these additional activities.

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Leisure Operator’s Checklist: Only exercise professionals qualified in Level 3 Exercise Referral will be involved in designing, agreeing, adapting and reviewing the patient’s physical activity programme. This is to maintain the quality of the scheme delivery and ensure patient safety. By following the checklist in these quality operating standards exercise professionals can ensure the service delivery is consistent, is NICE compliant, and follows best practice guidance from the BHF. In addition the monitoring and evaluation can be used to for benchmarking and demonstrate the effectiveness of the scheme both internally and externally to key stakeholders such as the district/borough councils, the referring healthcare professionals and the CCGs.

Read and follow the quality operating standards in this document and adhere to the service levels.

Make initial contact within seven days with the patient to arrange the first appointment if the referral is sent to the facility by the referring healthcare professional.

If the patient is unable to speak with a member of staff and leaves a message the leisure operator will respond to the patient within seven days to arrange an appointment.

Once initial contact is made between the delivery partner and patient the patient will be offered an initial consultation with the exercise professional within 2 weeks.

Advise the patient that they must bring their referral form to the initial consultation, wear suitable clothing / footwear and inform them of the patient responsibilities detailed in this document.

Only accept referrals that meet the criteria and you have sufficient competency to safely programme physical activity for. Only one referral per patient is permitted, in exceptional circumstances this may be waivered at the discretion of the scheme coordinator.

Ensure the service complies with the Equalities Act 2010 and makes reasonable adjustments for patients with physical disabilities, learning disabilities and mental health problems.

At Initial consultation conduct a lifestyle assessment, PARQ/risk stratification and check patient’s blood pressure and pulse to confirm the patient doesn’t have any contra-indications to exercise. Jointly develop with the patient an activity plan including activities inside and outside the leisure facility.

Complete an induction with the patient, taking into account relevant evidence based behaviour change techniques.

If the patient answers yes to any of the questions on the PARQ then they should be risk stratified using the Irwin Morgan risk stratification tool on pages 13-14. Only patients who fall into the low and medium risk categories should be accepted onto the scheme and will be given an individualised exercise programme relevant to their condition.

If the patient indicates they have unhealthy lifestyles on the initial Lifestyle Assessment, provide brief advice and signpost towards support services e.g. Stop Smoking Service.

Follow the consultation check list when conducting initial consultation detailed in the scheme quality operating standards in appendix 4.

If any medical concerns are identified at the initial consultation, the patient will not be able to participate in the programme, until a completed physical activity clearance/ change in health form has been received from their GP, clearing them for exercise.

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Inform the patient they are entitled to at least 12 weeks usage of the leisure facility, at the reduced rate.

Book and conduct review sessions are for weeks 4 and 8**, where the activity programme is reassessed.

Inform patients if they repeatedly DNA booked appointments, they may be discharged from the scheme. Re-entry into the scheme at a later date is at the discretion of the facility manager.

Create a physical activity programme suited to the needs/ medical condition of the referral patient, including SMART goals.

Take and record and monitor relevant body measurements at the start, review appointments and on exit of the programme.

Support the referral patient, with advice on physical activity, mobility and movement, including progression of exercises; as well as advice of activities upon exiting the scheme.

Make at least two follow up contacts with patients who do not attend the initial consultation, follow up reviews and exit appointments.

Make follow up phone calls to establish physical activity levels at 6 and 12 months post scheme exit/completion. For follow up calls at both 6 and 12 months at least two attempts should be made to contact the patient to establish their physical activity levels.

Adhere to leisure operator’s health and safety policies to ensure the safety of

patients.

Ensure exercise professionals have accredited fitness qualifications including an accredited Level 3 in Exercise Referral, recognised by the Register of Exercise Professionals (REPs), first aid training and a clear disclosure and barring service (DBS) where necessary. Delivery staff should also have the relevant insurance cover in place.

Deal with any complaints in a prompt and efficient manner using the leisure operator’s local complaints procedure.

Notify the patient’s GP if any deterioration in the patient’s health, by using the physical activity clearance/ change in health form.

At week 12/on exit**, review patient’s progress to date and discuss exit routes to remain physically active. Feedback on the scheme, via the referral scheme appraisal form and case study template are to be completed.

Follow up phone call of patients who complete the scheme to assess physical activity levels at 6 and 12 months post exit.

Complete the monitoring and evaluation data returns as detailed within these quality operating standards.

Facility managers have responsibility to oversee exercise professionals adhere to all parts of this checklist. * In compliance with NICE behaviour change guidance. **Review and exit session timescales may be subject to district/borough variation.

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Irwin Morgan Risk Stratification Tool: The PAR-Q must be used as the initial screening tool. If the patient answers ‘no’ to all the questions, their blood pressure is less than 140/90 and their heart rate is regular and less than 100 beats per minute, the risk of exercise is low. Such patients should remain within the exercise referral scheme. If the patient answers ‘yes’ to one or more questions, the exercise professional must then use the Irwin and Morgan risk stratification tool as covered in their Level 3 Exercise Referral training course . Medium risk patients must be entered into an individualised, supervised exercise programme relevant to their condition, and high risk patients are excluded from the scheme and must be referred back to the original referring healthcare professional for a referral to specialist exercise rehabilitation e.g. Cardiac or Pulmonary Rehabilitation.

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Patient’s Responsibilities: These quality operating standards will not be read by patients so the referring healthcare professional should inform the patient of the first two responsibilities and the exercise professional should cover the remainder at the initial consultation.

To make contact with the leisure venue/scheme coordinator to schedule their initial consultation, as soon as possible after visiting the referring health professional (e.g. GP).

To bring their referral form with them to the first appointment and give it to the instructor/ referral coordinator.

To schedule and attend review sessions with the exercise professional and provide at least 24 hours’ notice of any appointment cancellations.

To answer health, diet and fitness questions truthfully.

To participate in jointly developing with the exercise an activity plan.

For health and safety reasons, to ask the exercise professional if they are unsure on how to perform any of the suggested exercises, or how to use a piece of equipment.

Notify a staff member if they feel unwell during their session or whilst doing physical activity outside the leisure facility.

Advise the exercise professional and contact their GP if their health deteriorates.

To wear suitable clothing to participate in physical activity.

To provide feedback on the service on completion of the scheme (scheme appraisal questionnaire/ case study).

Pay per session fees or direct debit.

Patients are only entitled to access the scheme over the 12 week period where they had their initial consultation with the exercise professional.

Patient’s Safety: At the initial consultation, if any concerns arise about the patient being

medically fit to participate in the scheme, the GP or healthcare professional who has access to the patient’s records will need to provide clearance for the patient to participate, by using the physical activity clearance/ change in health form and return to the exercise professional.

If the patient’s referring GP or healthcare professional becomes aware of a change in the patient’s health, which may be affected by physical activity, they need to complete a physical activity clearance/ change in health form and send it to the exercise professional.

When sending physical activity clearance/ change in health forms, mark as ‘confidential’ and ensure the information is sent securely in compliance with the Data Protection Act. Patient data should not be exchanged via unsecure email addresses or fax machines unless they are designated ‘safe haven’ fax machines.

The leisure operator is responsible for risk assessing the environment, obtaining the relevant insurances, employing suitably qualified staff and ensuring they comply with the organisation’s/REPS code of conduct.

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Monitoring and Evaluation: The leisure operator will supply their local district/borough council and Hertfordshire County Council (HCC) through Public Health with monitoring and evaluation data on a quarterly basis (or when requested) for analysis. This is to help assess the quality and performance of the scheme and to see if activity participation increases. The evaluation process should meet the NICE guidance for exercise referral schemes by collecting and reporting the data fields included in the Standard Evaluation Framework (SEF) for Physical Activity Interventions. The data fields below will be collected and reported to evaluate scheme outcomes. Other sources of data may be used to aid process evaluation such as feedback from stakeholders and ‘secret shoppers’ who may access the scheme to assess the patient experience and ensure the quality operating standards are working and being adhered to. Individual patient manual records must be kept in a secure, locked filing cabinet, electronic records must be password accessible only, all records to be retained for a 5 year period in line with best practice guidance. In addition, where swipe card/MRM systems are in place schemes should utilise their reporting function to monitor facility usage by exercise referral patients. Monitoring and evaluation data should be collected and collated on a rolling ongoing basis. Each delivery site will be reminded to complete the quarterly Excel monitoring data template and email it to their local district/borough council and Public Health contacts outlined in appendix 2 within two weeks of the financial quarter end, ensuring all data fields are fully populated. The quarterly report should include the following as a minimum dataset:

Number of new starters on the referral scheme (including gender, age, ethnicity, disability).

Numbers from each referral source.

Numbers of referrals broken down by referral medical condition.

Starters initial number of days per week patients achieving moderate physical activity for 30 minutes (baseline physical activity level).

Number of patients dropping out of the scheme and reasons why.

Number of patients competing/exiting the 12 week* intervention.

Completers exiting number of days per week patients achieving moderate physical activity for 30 minutes (exit physical activity level*).

Member conversion rate of completers/exiting the 12 week** intervention.

Scheme appraisal and case study feedback from patients and exercise professionals. At least one case study per delivery site per quarter.

Follow up phone call of patients who complete the scheme to assess physical activity levels at 6 and 12 months post exit with breakdown of numbers contacted and the numbers who report an increase or decrease in their physical activity levels.

Compliments, complains and outcomes of how these were resolved. Scheme monitoring and evaluation summary reports will be sent quarterly by Public Health at HCC to Herts Valleys and East and North Hertfordshire CCGs for dissemination to primary care localities.

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Periodically county wide meetings will be held to discuss scheme monitoring, evaluation and performance. Representation will be sought from all Hertfordshire Exercise Referral Scheme delivery partners, council contacts as detailed in appendix 2 and CCG representatives to help ensure the scheme is running smoothly and improvements can be made if required. * For schemes longer than 12 weeks report of activity levels at 12 weeks and exit required ** For schemes longer than 12 weeks conversion rate to be calculated at time of exit

Key Stakeholders: Roles and Responsibilities Participating Leisure Operators - Sign up to operate exercise referral to the Hertfordshire Exercise Referral

Scheme Quality Operating Standards. - To adhere to the scheme standards. - To participate in scheme reviews. District and Borough Councils - Sign up to endorse the Hertfordshire Exercise Referral Scheme Quality

Operating Standards. - To work in partnership with their local leisure operator to ensure the scheme

standards are implemented and adhered to. - To participate in scheme reviews. CCGs - Sign up to endorse the Hertfordshire Exercise Referral Scheme Quality

Operating Standards. - To work in partnership with referring healthcare professionals to promote use

of the scheme, collate any scheme feedback from referring healthcare professionals and cascade scheme reports from Public Health.

- To participate in scheme reviews. HCC – Public Health - To lead the development of Hertfordshire Exercise Referral Scheme Quality

Operating Standards. - Sign up to endorse the Hertfordshire Exercise Referral Scheme Quality

Operating Standards. - To collate scheme monitoring and evaluation information and report it to the

CCGs. - To participate in scheme reviews.

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Summary:

The Hertfordshire Physical Exercise Referral Scheme allows inactive individuals with established medical conditions the opportunity to become active in a safe and friendly environment. Suitably qualified exercise professionals support and encourage patients in their pursuit of an active healthy lifestyle. The scheme recognises everyone benefits from physical activity, but not all individuals benefit from the same type of physical activity, so plans will be tailored to the individual patient’s needs. The skill of the exercise professional is not merely to prescribe the correct intensity, frequency, duration and type of activity; it is to prescribe the correct activity in consultation with the individual in order to have something they will enjoy and adhere to in the long-term behaviour change.

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APPENDIX 1: Hertfordshire Exercise Referral Scheme Delivery Facilities

DISTRICT

LEISURE

OPERATOR

ADDRESS

MANAGER

DELIVERY

INSTRUCTOR

TEL.

NUMBER

Broxbourne

Broxbourne Borough Council

Laura Trott Leisure Centre Windmill Lane Cheshunt EN8 9AJ

Tracy Brannick

ON HOLD ON HOLD

Broxbourne Borough Council

The John Warner Sports Centre Stanstead Road Hoddesdon EN11 0QG

Tracy Brannick

James Clark 01992 445375

Dacorum

Sportspace Sportspace Hemel Hempstead Park Road Hemel Hempstead Hertfordshire HP1 1JS

James Sexton

Karen Brown 01442 507107

Sportspace Sportspace Berkhamsted Lagley Meadow Douglas Gardens Berkhamsted HP4 3QQ

James Sexton

Karen Brown 01442 507107

East Herts

Everyone Active

Grange Paddocks Pool and Gym Rye Street Bishop's Stortford Herts CM23 2HH

Mike Weston

Kelly Rowlands

01279 652 332

Everyone Active

Fanshawe Pool and Gym Park Road Ware Herts SG12 0DP

Helen Asker

Dan Bryan 01992 584 000

Everyone Active

Leventhorpe Pool and Gym Sawbridgeworth Cambridge Road Essex CM21 9BY

Lawrence Lucas

Kelly Rowlands

01279 652 332

Everyone Active

Hartham Leisure Centre Hartham Common Hertford SG14 1QR

Francesca Brady Ian Ling

Dan Bryan 01992 584 000

Hertsmere

Hertsmere Leisure

The Venue 1 Elstree Way Borehamwood WD6 1J

Charlotte Hunt

Steve Berman 0208 386 9886

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Hertsmere Leisure

Bushey Grove Leisure Centre Aldenham Road Bushey WD23 2TD

Bridget Kirwan

Mick Brown 01923 470140

Hertsmere Leisure

Furzefield Leisure Centre Mutton Ln Potters Bar EN6 3BW

Ben Dodhia Russell Casey 01707 850 540

North Herts

Stevenage Leisure Ltd

North Herts Leisure Centre Baldock Rd, Letchworth Garden City SG6 2ER

Juanita Prescott

Mark Jennings 01462 679311

Stevenage Leisure Ltd

Knights Templar Sports Centre Weston Way, Baldock SG7 6EY

Juanita Prescott

Laura Sheppard

01462 631300

Stevenage Leisure Ltd

Archers Health & Fitness Club Fishponds Rd, Hitchin SG5 1HA

Juanita Prescott

Maria Esson 01462 437111

Stevenage Leisure Ltd

Royston Leisure Centre Woodcock Rd, Royston SG8 7XT

Juanita Prescott

Gemma Day 01763 255190

St. Albans

1Life Harpenden Sports Centre Leyton Rd Harpenden AL5 2HU

Andrzej Juraszek

Maggie Taleb 01727 819253

1Life Batchwood Golf Course & Sports Centre Batchwood Dr St Albans AL3 5XA

Andrzej Juraszek

Maggie Taleb 01727 819253

1Life Cotlandswick Leisure Centre 341 High St London Colney St Albans AL2 1EB

Andrzej Juraszek

Maggie Taleb 01727 819253

1Life Westminster Lodge Leisure Centre Holywell Hill St Albans AL1 2DL

Andrzej Juraszek

Maggie Taleb 01727 819253

Stevenage Stevenage Leisure Ltd

Healthy Hub Stevenage Lytton Way Stevenage Herts SG1 1LZ

Juanita Prescott

Chris Tillbrook 01438 242601

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Three Rivers

Hertsmere Leisure

The Centre Gosforth Lane South Oxhey Watford Hertfordshire WD19 7AX

Gavin Howard

Nick Evans

020 8428 4954

Hertsmere Leisure

William Penn Leisure Centre Shepherd's Lane Rickmansworth Hertfordshire WD3 8JN

Scott Beattie

Kelly McMillan 01923 771050

Watford and Three Rivers

Everyone Active

Woodside Leisure Centre Horseshoe Lane Garston Hertfordshire WD25 7HH

Janine Rogers

Tracy Fowler 01923 892710

Watford Everyone Active

Watford Central Leisure Centre Peace Prospect Watford Hertfordshire WD17 3HA

Raphael Debnatch

Joseph Brooks 01923 296750

Welwyn Hatfield

University of Hertfordshire

University of Hertfordshire Sports Village De Havilland Campus Hatfield AL10 9EU

David Connell

Nick Poulakis 01707 281182

Finesse Leisure

Hatfield Swim Centre

Karol Butrimas-Gair

John Achilles 01707 276276

Finesse Leisure

Hatfield Leisure Centre

Karol Butrimas-Gair

ON HOLD ON HOLD

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APPENDIX 2: Council Contacts

District/Borough Councils Contact

Broxbourne Tracy Brannick tracy.brannick@broxbourne.gov.uk

Dacorum Isobel Benton-Slim isobel.benton-slim@dacorum.gov.uk

East Herts Mark Kingsland mark.kingsland@eastherts.gov.uk

Hertsmere Rebecca Young rebecca.young@hertsmere.gov.uk

North Herts Steve Crowley steve.crowley@north-herts.gov.uk

St. Albans Emma Edgell emma.edgell@stalbans.gov.uk

Stevenage Hannah Marsh hannah.marsh@stevenage.gov.uk

Three Rivers Kelly Barnard kelly.barnard@ThreeRivers.gov.uk

Watford Caroline Roche caroline.roche@watford.gov.uk

Welwyn Hatfield David Snushall D.Snushall@welhat.gov.uk

Hertfordshire County Council (Public Health)

Tom May tom.may@hertfordshire.gov.uk

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APPENDIX 3: Summary of NICE Guidance on Exercise Referral NICE guidance (PH54) 2014 looked at exercise referral schemes that try to increase physical activity which focussed on:

• People who are sedentary or inactive • People who have an existing health condition (for example, coronary

heart disease, diabetes or depression) • People who have other risk factors for disease, such as being overweight

or obese, having raised blood pressure or cholesterol levels, or experiencing mild depression, anxiety or stress.

They recognise exercise referral schemes are popular and they may offer other benefits aside from physical activity, such as helping people to socialise, providing a means of getting involved with the community and providing affordable access to facilities. However they found no evidence of the impact on these outcomes in the evidence of effectiveness and cost effectiveness. In conclusion NICE were unable to judge the effect of exercise referral schemes on these outcomes, compared with other interventions that seek to address the same issues. NICE recommend exercise referral schemes should consist of all the following components:

An assessment by a primary care or allied health professional that the individual is sedentary.

A referral to a physical activity service. E.g. Leisure Operator.

A personal assessment to determine what physical activity programme will meet needs of the individual.

An opportunity to participate in a physical activity programme.

The latest NICE guidance on exercise referral (PH54) gives clear direction to commissioners stating; “Commissioners should only fund exercise referral schemes for people who are sedentary or inactive and have existing health conditions or other factors that put them at increased risk of ill health if the scheme:

Incorporates the core techniques outlined in recommendations 7–10 of 'Behaviour change: individual approaches' NICE public health guidance 49 This includes:

o Recognising when people may or may not be more open to change.

o Agreeing goals and developing action plans to help change behaviour.

o Advising on and arranging social support.

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o Tailoring behaviour change techniques and interventions to individual need.

o Monitoring progress and providing feedback o Developing coping plans to prevent relapse.

Collects data in line with the 'essential criteria' outlined in the Standard

Evaluation Framework for physical activity interventions. Makes the data collected available for analysis, monitoring and research

to inform future practice.” Furthermore NICE also recommend that Primary Care Practitioners only refer patients to schemes that fulfil the above criteria.

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APPENDIX 4: Scheme Forms and Checklists

Form 1: Referral Form Form 2: PARQ Form 3: Checklist for Exercise Referral Consultation with Exercise Professional Form 4: Lifestyle Assessment Form 5: Initial Physical Activity Assessment Form 6: 4 and Week Review Form 7: 12 Week Exit Review Form 8: Scheme Appraisal Questionnaire Form 9: Physical Activity Clearance / Change in Health Form Form 10: Case Study Template

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Hertfordshire Exercise Referral Scheme: REFERRAL FORM

Patient Details (Please Print Clearly)

First Name: Surname: Gender: M / F DOB: Home Tel: Mobile Tel: email: GP: GP Practice: Patient Address: Patient Postcode:

Reason for referral: Inactive AND (Please tick at least one of these other criteria)

☐Hypertension - Controlled ☐Osteoporosis

☐ Asthma - Controlled

☐Diabetes - Controlled ☐Low Back Weakness and

Inflexibility

☐Unhealthy Weight

(BMI > 24.9 kg/m²)

☐Osteoarthritis

- Mild to Moderate

☐High Cholesterol Levels

(total > 5.2 mmol/L)

☐Mental Health Condition

- Mild to Moderate

☐Rheumatoid Arthritis

- Mild to Moderate

☐Chronic Obstructive

Pulmonary Disease – Mild to Moderate

☐Musculoskeletal

Rehabilitation

☐TIA/Stroke - >1 year ago, Stable CV symptoms, mobile and no assistance required

☐Other (please state) ...........................................................................

Relevant Medication (s)

Blood Pressure: Systolic: Diastolic: Resting Heart Rate:

Healthcare Professional Declaration: (Please Tick)

I am not aware of any contra-indication to physical activity for this referred patient. ☐

The patient has given their informed consent for the information on this form to be

shared with the providers of the exercise referral scheme in Hertfordshire. ☐

Print Name: Profession: Date: Referring Healthcare Professional Office Base: IMPORTANT PATIENT INFORMATION: WHAT NEXT? 1) Call your local participating leisure facility to arrange your first appointment. 2) You must bring this form with you for your first appointment. Click Box to Select Leisure Centre:

Additional comments / Relevant conditions / Physical Limitations

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Hertfordshire Exercise Referral Scheme: Patient Information Sheet What is the Exercise Referral Scheme? The Exercise Referral Scheme has been created to help people with certain medical conditions become more active. We know sometimes becoming more active is hard so we a have a team of exercise specialists who will help you along that journey by providing support, guidance and motivation. What are the benefits of physical activity? Healthcare professionals recognise that exercise is one of the best medicines. It can be used to manage or prevent a range of health conditions including high blood pressure, high cholesterol, arthritis and diabetes. It can also reduce the risk of heart disease, help you maintain a healthy weight plus improve your mood and energy levels. What can I expect from the scheme? You will have a one to one appointment with a qualified exercise instructor, who will build a tailored activity programme with you which will take into consideration your likes and dislikes. They will also make sure the activities help any medical conditions you may have and support you in achieving your personal health and fitness goals. They will arrange to have review appointments with you at 4weeks, 8weeks and 12 weeks to support you and see how you are progressing. You will have access to the participating leisure facility of your choice for at least 12 weeks. Usually this will include use of the gym and swimming pool, however services may vary (please check what is available at your local leisure centre). What are the added benefits of being on the scheme? All of the instructors running the scheme have a specialist qualification in Exercise Referral which means that they understand your medical conditions and medications and can develop an exercise programme with you which is safe and appropriate for your needs. What does the scheme cost? Prices are subsidised and vary please contact your leisure centre of choice for details. What happens next? Once your healthcare professional has given you your referral form please phone the participating leisure centre of your choice to book your first appointment. Remember you will need to take your referral form with you to your first appointment. Where can I go? You can access any of the participating leisure centres on this back of this information sheet across Hertfordshire; however you must complete the whole course at the same centre.

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Hertfordshire Exercise Referral Scheme: Participating Leisure Centres

Area

Leisure Centre

Telephone no.

Broxbourne The John Warner Sports Centre, Hoddesdon (01992) 445375

Dacorum

Sportspace, Hemel Hempstead (01442) 507107

Sportspace, Berkhamsted (01442) 507107

East Herts

Grange Paddocks Pool and Gym , Bishop's Stortford (01279) 652 332

Fanshawe Pool and Gym, Ware (01992) 584 000

Leventhorpe Pool and Gym, Sawbridgeworth (01279) 652 332

Hartham Leisure Centre, Hertford (01992) 584 000

Hertsmere

The Venue, Borehamwood (0208) 386 9886

Bushey Grove Leisure Centre, Bushey (01923) 470140

Furzefield Leisure Centre, Potters Bar (01707) 850 540

North Herts

North Herts Leisure Centre, Letchworth Garden City (01462) 679311

Knights Templar Sports Centre, Baldock (01462) 631300

Archers Health & Fitness Club, Hitchin (01462) 437111

Royston Leisure Centre, Royston (01763) 255190

St. Albans

Harpenden Sports Centre, Harpenden (01727) 819253

Batchwood Golf Course & Sports Centre, St Albans (01727) 819253

Cotlandswick Leisure Centre, London Colney (01727) 819253

Westminster Lodge Leisure Centre, St Albans (01727) 819253

Stevenage Healthy Hub, Stevenage (01438) 242601

Three Rivers

The Centre, South Oxhey (0208) 428 4954

William Penn Leisure Centre, Rickmansworth (01923) 771050

Watford and Three Rivers

Woodside Leisure Centre, Garston

(01923) 892710

Watford Watford Central Leisure Centre, Watford (01923) 296750

Welwyn Hatfield

University of Hertfordshire Sports Village, Hatfield (01707) 281182

Hatfield Swim Centre (01707) 276276

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Checklist for Exercise Referral Consultation with Exercise Professional

Exercise professionals should incorporate evidence based behaviour change techniques when working with patients in all consultations as covered in their Level 3 Exercise Referral training. This complies with NICE guidance on behaviour change (individual approaches) which outlines the key components which should be covered:

Recognising when people may or may not be more open to change

Agreeing goals and developing action plans to help change behaviour

Advising on and arranging social support

Tailoring behaviour change techniques and interventions to individual need

Monitoring progress and providing feedback

Developing coping plans to prevent relapse

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Hertfordshire Exercise Referral Scheme: Lifestyle Assessment First Name: Surname:

Please circle which age band you are in:

16-24 25-34 35-44 45-54 55-64 65-74 Over 75 years

Tick one option that best describes your ethnic group or background

White

1. English/Welsh/Scottish/Northern Irish/British 2. Irish 3. Gypsy or Irish Traveller 4. Any other White background, please describe

……………………………………………………………………………………………………..

Mixed/Multiple ethnic groups

5. White and Black Caribbean 6. White and Black African 7. White and Asian 8. Any other Mixed/Multiple ethnic background, please describe ……………………………………………………………………………………………………….

Asian/Asian British

9. Indian 10. Pakistani 11. Bangladeshi 12. Chinese 13. Any other Asian background, please describe

………………………………………………………………………………………………………

Black/ African/Caribbean/Black British

14. African 15. Caribbean 16. Any other Black/African/Caribbean background, please describe ………………………………………………………………………………………………………

Other ethnic group

17. Arab 18. Any other ethnic group, please describe

……………………………………………………………………………………………………….

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Hertfordshire Exercise Referral Scheme: Lifestyle Assessment

1. How would you describe your current physical health?

POOR OK GOOD EXCELLENT

2. In the past week, on how many days have you done a total of 30 minutes or more of moderate intensity physical activity, which was enough to raise your breathing rate? This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job.

0 days1day2days3days4days5days6days7days

3. What moderate intensity physical activity do you participate in, on a regular basis? ......................................................................................................

4. How would you describe your eating habits? POOR OK GOOD EXCELLENT

5. Do you smoke? NO (go to Q6) YES (go to Q5a and Q5b) 5a. How many cigarettes/week? ..................................................................... 5b. Do you want help to quit smoking? NO YES 6. Do you drink alcohol? NO YES Units/week? .................................... 7. Family Medical History?

(E.g. heart disease, heart attack, stroke, high blood pressure, high cholesterol etc.)

......................................................................................................... 8. Muscle or joint problems & treatments(e.g. back, neck)

.......................................................................................................

9. Do you have a physical, mental health condition or learning disability? NO YES

10. How often do you hope to use the facility each week? ..................................... 11. What are your main aims and goals you hope to achieve through being more active?

1: ..................................................................................................

2: .................................................................................................. 3: .................................................................................................. Signed: Date:

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Hertfordshire Exercise Referral Scheme: Initial Physical Activity Assessment First Name: Surname: DOB: Date: Body Weight kg Height cm Blood Pressure (Pre Exercise) Systolic mmHg Diastolic mmHg Resting Heart Rate bpm *Body Composition Test Body Fat % = *BMI *Circumferences Waist cm Hips cm Ratio *= optional Motivation and Confidence How motivated are you to take part in regular physical activity which is enough to raise your breathing rate? (circle only one) Not Motivated Very Motivated

1 2 3 4 5 6 7 8 9 10

How confident are you to take part in regular physical activity which is enough to raise your breathing rate? (circle only one) Not Confident Very Confident

1 2 3 4 5 6 7 8 9 10

Planned activities within the Leisure Facility: 1) 2) 3) 4) 5) Planned activities outside the Leisure Facility: 1) 2) 3) 4) 5)

Date of 4 week review:

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Hertfordshire Exercise Referral Scheme: 4 and 8 Week Review

1. How would you describe your current physical health?

POOR OK GOOD EXCELLENT 2. In the past week, on how many days have you done a total of 30 minutes or more of

moderate intensity physical activity, which was enough to raise your breathing rate? This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job. 0 days1day2days3days4days5days6days7days

3. What moderate intensity physical activity do you participate in, on a regular basis? ......................................................................................................

Motivation and Confidence 4. How motivated are you to take part in regular physical activity which is enough to raise your breathing rate? (circle only one) Not Motivated Very Motivated

1 2 3 4 5 6 7 8 9 10

5. How confident are you to take part in regular physical activity which is enough to raise your breathing rate? (circle only one) Not Confident Very Confident

1 2 3 4 5 6 7 8 9 10

Planned activities within the Leisure Facility: 1) 2) 3) 4) 5) Planned activities outside the Leisure Facility: 1) 2) 3) 4) 5) Date of next review:

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Hertfordshire Exercise Referral Scheme: 12 Week Exit Review

Body Weight kg Blood Pressure (Pre Exercise) Systolic mmHg Diastolic mmHg Resting Heart Rate bpm *Body Composition Test Body Fat % = *BMI *Circumferences Waist cm Hips cm Ratio Motivation and Confidence How motivated are you to take part in regular physical activity which is enough to raise your breathing rate? (circle only one) Not Motivated Very Motivated

1 2 3 4 5 6 7 8 9 10

How confident are you to take part in regular physical activity which is enough to raise your breathing rate? (circle only one) Not Confident Very Confident

1 2 3 4 5 6 7 8 9 10

Planned activities within the Leisure Facility: 1) 2) 3) 4) 5) Planned activities outside the Leisure Facility: 1) 2) 3) 4) 5)

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Hertfordshire Exercise Referral Scheme: Scheme Appraisal Questionnaire

First Name: Surname: DOB: We hope you feel this scheme was of a benefit, please spend a little time completing the following questionnaire, to enable us to appraise the Scheme. Read the questions carefully and circle the most appropriate answer. All responses will be treated with strictest confidence.

Strongly Agree Neither Disagree Strongly Agree Disagree Disagree

Or Agree

1. Initial contact with the Exercise Professional was easy. 1 2 3 4 5

2. The Exercise Professional was helpful. 1 2 3 4 5 3. I was given a full explanation of

my jointly developed activity plan. 1 2 3 4 5

4. I feel I have a healthier lifestyle as a result of the Scheme. 1 2 3 4 5

5. I plan to continue with a Physical Activity plan once I’ve finished the Scheme. 1 2 3 4 5

6. I feel good about myself for participating on the Scheme. 1 2 3 4 5

7. During your time on the Exercise Scheme how many times did you exercise outside the Leisure Centre?

0 1-5 6-10 11-15 16+

8. Would you recommend the scheme to others? YES NO 9. In the past week, on how many days have you done a total of 30 minutes or more of moderate

intensity physical activity, which was enough to raise your breathing rate? This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job. (tick one box only) 0 days1day2days3days4days5days6days7days

10. Do you plan to remain physically active after completing the Scheme? YES NO 11. Any other comments regarding the Scheme:

THANK-YOU FOR COMPLETING THIS FORM, WE VALUE YOUR VIEWS.

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HERTFORDSHIRE EXERCISE REFFERAL SCHEME

Physical Activity Clearance / Change in Health Form: GP notification to Scheme Manager

Print Patient Name: DOB:

The above named patient has had a change in their health as detailed below which I feel the scheme manager should be aware of: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… As a result I advise that the patient: (Please tick one box below)

Has no medical reason why they should not participate in a physical activity programme.

Can participate in a physical activity programme with caution. (please specify details above)

Is not medically fit to participate in a physical activity programme at present and should not do so until further notice.

GP Details

Print Name: Signature: Date:

Practice Name:

SEND TO EXERCISE REFERRAL SCHEME MANAGER AT THE LEISURE FACILITY WHERE THE PATIENT IS ATTENDING. PLEASE MARK THE ENVELOPE PRIVATE AND CONFIDENTIAL.

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HERTFORDSHIRE EXERCISE REFFERAL SCHEME

Physical Activity Clearance / Change in Health Form: Scheme to GP

Print Patient Name: DOB: (Please tick)

Information observed by Exercise Referral Instructor

Information given to Exercise Referral Instructor by patient The above patient has experienced the following change in exercise tolerance or reported a health condition and we would appreciate your opinion on their ongoing participation on the scheme. They have been advised to stop their physical activity program until s/he has had clearance from you. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Exercise Professional

Print Name: Signature: Date: Facility patient is attending:

THIS SECTION TO BE COMPLETED BY PATIENT’S GP PLEASE TICK ONE OPTION BELOW AND SEND BACK TO THE SCHEME MANAGER AT THE LEISURE FACILITY WHERE THE PATIENT IS ATTENDING.

This patient is not cleared to continue with the physical activity programme

This patient is cleared to resume with the programme with no further restrictions

This patient may resume the programme but should avoid the following; ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ GP Details Print Name: Signature: Date: Practice Name:

PLEASE MARK THE ENVELOPE PRIVATE AND CONFIDENTIAL WHEN SENDING THIS FORM.

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Hertfordshire Exercise Referral Scheme Patient Case Study Template: Practitioner Statement

Facility Attended: Case Study No.: Date:

What was primary reason for referral?

How did you develop a tailored activity programme given the patient’s taking into account their conditions, goals and limitations

How did you monitor progress with the patient?

Resources Provided

What were the outcomes for the patient?

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Hertfordshire Exercise Referral Scheme Case Study Template: Patient Statement

Facility Attended: Case Study No.: Date: PLEASE LET US KNOW WHAT YOUR EXPERIENCE HAS BEEN ON THE HERTFORDSHIRE PHYSICAL ACTIVITY REFERRAL SCHEME AND WHAT DIFFERENCE IT HAS MADE TO YOU.