A Complete Guide To Exercise Referral Schemes

Introduction

Physical inactivity is now associated with 1 in 6 deaths in the UK. It’s also estimated to cost the UK £7.4 billion every single year according to a landmark government report [1]. With the rise of chronic illnesses and preventable long-term conditions showing no sign of slowing down, never has there been more of a need for high-quality Exercise Referral Schemes with qualified and experienced exercise referral instructors. Many of us are vaguely familiar with Exercise Referral Schemes, but how do they actually work? How simple is the referral system to access? And for anyone interested in becoming an exercise referral instructor, how long does it take to qualify? This article explains…

What Is An Exercise Referral Scheme?

Exercise Referral Schemes help people with specific medical conditions improve their health and wellbeing through physical activity and lifestyle modifications. People are typically referred to Exercise Referral Schemes by primary healthcare professionals (e.g., a GP) if they have one or more long-term conditions that could better managed or improved by specialist exercise programming.

When a client enrols on an Exercise Referral Scheme, the instructor and client agree on an appropriate form of exercise that suits the client’s personal and clinical goals. Exercise programmes focus on improving outcomes associated with the client’s long-term medical condition(s) and help them become as independently active as possible.

Exercise Referral Schemes are usually available to patients for 8 to 12 weeks, although some schemes do run over longer periods of time. Schemes (including broader health and wellbeing initiatives) can also be seen as an alternative to conventional medical interventions, for example, prescription medications and/or surgery. Ultimately, referral schemes are designed to help patients take greater responsibility for their own health and reduce future dependency on the healthcare systems for managing their condition(s).

Who Is Eligible For Exercise Referral Schemes?

Eligibility for an Exercise Referral Scheme in the UK varies geographically according to regional health priorities. Local councils and NHS services work alongside Integrated Care Boards (ICBs) to set their own criteria based on prominent health issues in the area. As NHS England explain, ‘Integrated Care Boards (ICBs) are NHS organisations responsible for planning health services for their local population. They manage the NHS budget and work with local providers of NHS services, such as hospitals and GP practices, to agree where their funding is directed [2].’ While each Exercise Referral Scheme has its own unique inclusion criteria, some of the most common long-term conditions that the schemes support are listed below.

• Diabetes (Type 1 or Type 2)
• Respiratory conditions (asthma, COPD)
• Musculoskeletal conditions (arthritis, osteoporosis)
• Mental health conditions (depression, anxiety)
• Cardiovascular diseases (hypertension, heart disease)
• Neurological conditions (multiple sclerosis, Parkinson’s disease)

Most of these conditions can be improved, or at least better managed, if the appropriate level and type of exercise are regularly performed. Patients referred to a referral scheme will also likely be taking multiple medications, meaning instructors must have specialist knowledge about the effects of these medications, so that they do not recommend exercises that negatively interact with these medications (e.g., some medications may lower blood pressure; exercises which cause rapid changes in blood pressure may increase the risk of dizziness, fainting, or other adverse outcomes).

To be eligible for an Exercise Referral Scheme, patients must usually be over 16 years of age, inactive (typically performing less than 30 minutes of physical activity per week), compliant with any medications they are being prescribed, and demonstrate an open and willing attitude to embark on a behaviour change course focused on exercise, physical activity and healthy eating.

How Does An Exercise Referral Scheme Work?

Although every Exercise Referral Scheme has its own specific inclusion criteria and procedures, they typically all involve each of the following steps listed below:

Step 1: Client Referral

Most commonly, a qualified medical professional refers a patient to an Exercise Referral Scheme to engage in a supervised exercise programme alongside other behaviour change initiatives. The scheme coordinator or manager will then accept or reject the referral depending on the specific rules of the scheme. Doctors will not typically refer patients to individual instructors, although they may recommend patients to local services that might be useful, for example Pilates classes for people with LBP.

Step 2: Health Assessment

The patient will meet with their allocated exercise referral instructor for an initial consultation. The consultation involves a number of health screenings and risk assessment activities before the instructor can start to design the exercise programme. Programmes vary between schemes and the patient’s preference, but they often include a combination of gym-based exercise, low-impact aerobic activities, yoga and Pilates classes, outdoor community events such as walking, or tailored sporting activities, such as walking football.

Step 3: Exercise Programming

The programme is designed, implemented, and the exercise referral specialist supervises the patient throughout their exercise journey. Exercise is usually supervised, especially in the early stages of the programme, to ensure that there are no adverse responses and to maximise safety. Most Exercise Referral Schemes are free to patients at the point of access (or heavily subsidised), so the scheme will usually track attendance, engagement, and progress to ensure that the funding body (e.g., local authority, NHS) is getting value for money.

Health markers (e.g., blood pressure, blood sugars, HbA1c, cholesterol profiles) are often measured to see how patients are responding to the programme, although different schemes will have different rules on this. These assessments may be taken by nurses operating from within the scheme, especially where they involve blood. Regular reports may also be provided to the referring healthcare professional, but some schemes may only report on this at the end of the client’s exercise referral journey. Most Exercise Referral Schemes will run between 8 to 12 weeks, but 16-week programmes are not uncommon either. This broadly depends on a combination of the patient’s condition(s), circumstances, and funding restrictions.

Step 4: Final Assessment

The instructor and client meet for a final assessment. It’s at this stage that the instructor and the management team of the scheme will establish whether the programme has effectively improved the client’s health based on the aims of the programme and the client’s starting point. In some situations, the programme may be extended, although this is not common due to funding constraints. Typically, clients are given a limited time on exercise referral programmes with the goal of making them confident enough to be able to manage their basic exercise and physical activity levels more independently. On exit from the scheme, a report is provided to the referring clinician (e.g., GP) and clients will usually receive some form of follow-up in the weeks, months, sometimes even years after the scheme to provide further support if needed.

How Can Exercise Referral Improve Clients’ Health?

Exercise Referral Schemes were introduced in the UK in the 1990s as part of a public health initiative to address rising levels of chronic diseases associated with physical inactivity. The primary goal was to promote physical activity as a form of preventative healthcare. Hundreds upon hundreds of studies have been published to support the position that people who exercise daily for a minimum of 30 minutes are considerably less likely to develop chronic illnesses like diabetes, obesity, high cholesterol (also known as long-term conditions). We now also know that those who have these long-term health conditions and who make changes to their physical activity levels, are much more likely to experience marked improvements in their health – often to a greater extent than with medication alone.

Do Exercise Referral Schemes Really Work?

While research is limited, there is evidence to suggest that Exercise Referral Schemes are effective for changing health and lifestyle-related behaviours in the short-medium-term. The National Institute for Health Care and Excellence (NICE) found that those on Referral Schemes were 12% more likely to achieve 90 to 150 minutes of at least moderate level of exercise per week compared to those not involved in a scheme. The study also found that, on average, Exercise Referral Schemes increased the number of minutes per week of physical exercise over 55 minutes [3].

But none of this is to say the schemes don’t come without their challenges. A National Library of Medicine report found that the overall risk reduction of those on the schemes was relatively small. ‘It takes 17 sedentary people to be referred for just one to become moderately active [4]’. This was most likely due to poor participation and compliance rates – a much wider issue affecting the health, fitness, and wellbeing industry.

Changing people’s behaviour and habits is more than just making them accountable for what they do on a daily basis. There are also a number of key mental and emotional factors that must be satisfied if people are going to be motivated to make a change to their lifestyle, let alone sustain it over the long-term. Getting people to simply engage in exercise for a 12 to 16-week period is not enough. It is likely that they will need coaching or counselling to support them to resolve their ambivalence about the change.

Lee Cain, HFE Managing Director says:

“Exercise referral schemes are broadly effective in getting patients to engage in lifestyle-related behaviour change for the duration of the programme. However, once clients leave the scheme, engagement with these behaviours appears to drop, largely because the underlying psychological mechanisms have not been addressed. We now know using person-centred behaviour change conversations have better long-term effects on adherence. It feels logical to me to incorporate interventions like these into exercise referral services to maximise the impact they have on health outcomes.“

What Does An Exercise Referral Instructor Do?

Exercise referral instructors are responsible for designing and implementing specialist exercise programmes for referred patients. The activities delivered depend on the qualification status of the instructor. This means instructors can only deliver activities in which they hold appropriate qualifications (e.g., gym-based exercise, group exercise to music, Pilates, or yoga). The following are just some examples of activities that exercise referral instructors might deliver, depending on their qualifications:

• Walking programmes (outdoors or on a treadmill)
• Cycling (stationary bike or outdoor)
• Swimming or aqua aerobics
• Resistance training and/or bodyweight exercises
• Yoga or Pilates-based exercises*
• Chair-based exercises (for those with mobility issues)*
• Exercise to music and/or simple circuit training*
• Sports activities (walking football, netball, basketball)*

*These activities are also designed to create a sense of camaraderie, togetherness, and cohesion within a group environment.

Working in an exercise referral setting can be one of the most rewarding careers for health and fitness professionals to pursue. Often, those attracted to these roles are motivated by a sense of ‘giving back’ to people who need it most.

A good exercise referral instructor will need to have strong interpersonal skills, and be empathic, understanding, and compassionate with their clients and their needs. The role also requires strong technical skills. Instructors will need to be able to develop a strong understanding of the pathology and physiology of a wide-range of complex long-term medical conditions, so they can design and implement effective and safe exercise programmes for their clients.

How To Qualify As An Exercise Referral Instructor?

Exercise referral instructors must hold a Level 3 Diploma in Exercise Referral to become a qualified instructor. To enrol on the course, learners must:

• Hold a recognised Fitness Instructor qualification (level 2)
• Hold a current Level 3 Anatomy and Physiology unit*
• Hold a current Level 3 Nutrition for Exercise and Physical Activity qualification*

*These units and qualifications are usually completed as part of a personal training qualification. Those who do not have a Level 3 Diploma in Personal Training typically need to complete these elements alongside their Exercise Referral qualification.

Instructors might also need insurance to cover themselves and their patients. If they are employed by an Exercise Referral Scheme, they will likely be covered by the schemes own insurance policy, but it is always wise for instructors to check this with their scheme coordinator. If instructors are self-employed or delivering sessions on a freelance basis, they will likely need to arrange their own insurance. Professional Indemnity Insurance and Public Liability Insurance are the two most common types of insurance used by exercise professionals.

Public liability insurance covers accidents or accidental injuries to clients during sessions. Professional indemnity insurance covers legal costs if a client claims their instructors advice or treatment caused them harm.

Public liability insurance is a legal requirement, whereas professional indemnity insurance is not, although it is best practice to hold it, especially when working with higher-risk clients like those in an Exercise Referral Scheme.

What Exercise Referral Job Opportunities Are Available?

There are a number of different avenues exercise referral instructors can take once qualified. They can work in a gym, health club, or for a local council that has a contract with the NHS or local authority to provide health and wellbeing services like exercise referral. Many of the local authority leisure facilities have now been contracted out to private sector and not-for profit organisations. These are much more likely to be providing exercise referral services.

Instructors can even work for the NHS directly. There are no shortage of specialist exercise, fitness, and wellbeing type roles available. At the time of writing, a quick search on the NHS Careers website revealed a number of opportunities available in this field for qualified instructors.

It is important to once again underline that qualified instructors do not take referrals directly from doctors or other clinicians. Patients are referred into formal exercise referral schemes that are funded and regulated externally by different types of professional organisations. This is a common myth associated with exercise referral.

Instructors can work in exercise referral in a variety of organisations, including, but not limited to:

• NHS
• Primary care trusts
• Charitable trusts
• Non-profit organisations
• Local authorities
• Schools, colleges, and universities
• Private health clubs

Ready To Get Started?

If you asked any exercise referral instructor about their role, they will tell you it’s a rewarding and fulfilling career that gives you a purpose, and the opportunity to meet a range of different and interesting people every day. If you’re ready to get started now, head over to our Level 3 Diploma in Exercise Referral course page or speak to our team on 0800 612 4067.

References

[1] Office for Health Improvement and Disparities. (2022, March 10). Physical activity: Applying All Our Health. GOV.UK. https://www.gov.uk/government/publications/physical-activity-applying-all-our-health/physical-activity-applying-all-our-health

[2] National Health Service England. (2022). What Are Integrated Care systems? NHS England; NHS England. https://www.england.nhs.uk/integratedcare/what-is-integrated-care/

[3] Campbell, F., Holmes, M., Everson-Hock, E., Davis, S., Woods, H. B., Anokye, N., & et al. (2015). A systematic review and economic evaluation of exercise referral schemes in primary care: A short report. Health Technology Assessment, 19(60). https://doi.org/10.3310/hta19600

[4] Williams, N. H., Hendry, M., France, B., Lewis, R., & Wilkinson, C. (2007). Effectiveness of exercise-referral schemes to promote physical activity in adults: Systematic review. British Journal of General Practice, 57(545), 979–986. https://doi.org/10.3399/096016407782604866

[5] Hanson CL, Allin LJ, Ellis JG, et alAn evaluation of the efficacy of the exercise on referral scheme in Northumberland, UK: association with physical activity and predictors of engagement. A naturalistic observation studyBMJ Open 2013;3:e002849. doi: 10.1136/bmjopen-2013-002849