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    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 patients 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 patients 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 Professionals Checklist 9

    Duration of Scheme 10

    Scheme Pricing 10

    Leisure Operators Checklist 11-12

    Risk Stratification Tool 13-14

    Patients Responsibilities 15

    Patients Safety 15

    Monitoring and Evaluation 16-17

    Key Stakeholders: Roles and Responsibilities 17

    Summary 18


    APPENDIX 1 Hertfordshire Exercise Referral Scheme Delivery Facilities


    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


    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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    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


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