Premium

The newest way to treat chronic illness – and no, it's not more drugs 

exercise 
In the US, it is considered like any other prescription, with a type, dose, frequency, duration and therapeutic goal

Swapping medication for gym memberships can reverse the risk of chronic illness and save the NHS money, finds Victoria Lambert 

With new figures suggesting that type 2 diabetes is costing the NHS an estimated £22million a day, it is no wonder that doctors and managers are scouting around for new ways to prevent and treat chronic illnesses.

Perhaps the most inexpensive – and surprising - lies in a little-known scheme that relies less on medicine and more on common sense: exercise on prescription.

John Lee, 45, a father of five from Stockport, where he lives with wife Lisa, 47, was certainly taken aback to be offered activities instead of tablets when he was called in unexpectedly to see his GP.

“My doctor told me I was almost diabetic,” Lee says, three years later. “That I was obese and needed to lose weight. I’d always said to him not to sugar coat any bad news – and he didn’t. He was direct.”

Lee was given an “exercise prescription” and put on the Physical Activity Referral in Stockport (PARiS) exercise referral scheme.  This involves a free gym membership and exercise programme with a trainer for 12 weeks initially – although this can be extended.

John Lee (right) with Paul Lindley, exercise referal specialist. Credit: Lorne Campbell/Guzelian 

A full gym membership would have cost Lee £39.50, and a personal trainer charges £35 a session so his prescription saved him £460 in total. 

“It was very hard at the beginning,” says Lee, “my body wasn’t used to it. But after a year, I’d lost half a stone and now, I’m down three stone overall.”

His blood sugar count has dropped reducing the risk of type 2 diabetes and the chronic asthma Lee had has also eased.

The reasoning behind offering exercise prescriptions is sound. The World Health Organisation (WHO) says physical inactivity is one of the 10 leading causes of death in developed countries and results in about 1.9 million preventable deaths worldwide annually.

In the US, it is considered like any other prescription, with a type, dose, frequency, duration and therapeutic goal. Swedish doctors have physical activity promotion as one of their main healthcare objectives.

But in the UK, these prescriptions are not on offer to everyone.  

It’s something of a postcode lottery, says Dr Andrew Boyd, Clinical Champion for Physical Activity and Lifestyle at the Royal College of General Practitioners (RCGP). What is available and how well integrated it is into local healthcare is hugely variable. “The challenge is integrating physical activity into routine conversations about health at every opportunity,” says Dr Boyd. 

And Dr Boyd adds that while the evidence for being physically active to help with chronic conditions is pretty uncontroversial, “You can’t expect three months of activity to make up for total inactivity up until that point. It only works if it is sustained.” That’s particularly true once you are over 40 – “There are measurable benefits to taking up exercise,” he says, “it can add on quality extra years to your life.”

Getting more patients to exercise could also help the NHS budget crisis “It is estimated that physical inactivity costs the NHS £1bn/annually (and the economy at large £7.4bn),” says Dr Boyd. “So if lifestyle interventions could empower even a percentage of the inactive population to get more active, the scope for savings could be enormous.

“An interesting statistic is that even a brief intervention from a doctor about getting more active is effective in 1 in 12 occasions, (which is a pretty good return on investment compared to e.g. smoking is 1 in 50-120).”

At Life Leisure, a social enterprise based in the north-west which operates sports and leisure facilities for the community - including the one John Lee attends - about 2,500 clients every year are recommended by a variety of practitioners.

Michelle Childs, health development manager, explains: “This scheme was one of the first in the country. It’s our 27th year and we are exceptionally lucky it has been invested in for that length of time.” Referrals come from GPs, practice nurses, physio and cardiac rehab teams – and the scheme is oversubscribed.

Childs adds: “About 70-75 per cent of those offered the prescription take it up and their conditions are varied from mental health and type 2 diabetes to musculoskeletal pain and after stroke. Key to the programme success is personalisation. “We begin with a 45-minute consultation to work out what they need,” she says. “From there, clients may choose gym work, Nordic walking, swimming or classes.”

John Lee before losing three stones in weight. Credit: Guzelian /Lorne Campbell 

In London, at the Portobello Fitness Club, General Manager Warren Albrecht oversees a partnership with The Westway Trust, a registered charity to provide exercise referrals for the local community.

The Portobello Fitness Club focuses on people with more complex health conditions and over the years, has introduced specialist programmes for medium and higher risk members, which sets them apart from your ‘traditional’ GP referral. Conditions can raise from disabilities to back pain and depression.

“Most people have more than one condition,” says Albrecht, “so we give them a one to one assessment and then set a plan and goals.”

At Portobello, exercise is only one possible route to health. “We can signpost to other organisations,” says Albrecht “if they need psychological support or motivational help. We can refer them for talking therapies for example.

“Exercise will get you benefits but ideally we offer a holistic approach.”

The Portobello programmes last 12 weeks (costing the NHS £60 per head) and after that, clients are encouraged to carry on at a subsidised rate.  “We want them to stay a member with us long term,” he says.

He cites one 72-year-old client who came to the club as an overweight smoker with chronic obstructive pulmonary disease (COPD). “He started exercising, lost weight and his breathing improved. 

“But what really stood out was how he developed a love of climbing – even though he had a fear of heights at first. Now we can’t get him off the wall and he does excursions across the country.”

Stockport GP Dr James Higgins who sends patients to Life Leisure thinks this kind of prescription is under-utilised by the NHS.

“We are recognising that lifestyle plays a key part in health,” he says, “and potentially there is more benefit to be had in communities in deprived areas where people are at risk of multiple conditions.”

Dr Higgins says the simple act of a conversation between doctor and patient can make a difference. “There is good evidence that even brief discussions about lifestyle,” he says, “especially if delivered regularly can move people along the cycle of change. Moving from the contemplation stage to the action stage is a difficult step, so conversation, along with a practical intervention to make that step easier is always a positive.”  

If his patients don’t like the idea of a gym, he is able to suggest T’ai chi classes or swimming classes.  “You have to find the exercise that fits your life.” His Trust is even piloting self-referrals to access the system so that people don’t have to see the GP to get accepted.

Lee working out under the supervision of Lindley Credit:  Lorne Campbell/Guzelian

So do exercise prescriptions work?

“Absolutely,” says Dr Higgins. “If you don’t fix your lifestyle issues, you can throw as many medications as you like at a problem and not get a result.”

At Portobello Fitness Club, Albrecht says he has a 60 per cent completion rate. At Life Leisure, Childs says there is a 53 per cent completion rate for the six-month course (which costs the NHS £100 per person). Beyond that, it’s hard to follow up with enough clients to get a proper picture, she says.

“We know a lot continue, some with us and some elsewhere like joining a walking group,” she says, adding: “Exercise does what all the evidence says it will: it improves mental health and reduces waist measurements and body mass index (BMI). People feel better about themselves.”

For John Lee, his unusual prescription has been heaven-sent – not just for him but the whole family. Once his exercise routine was established, Lee was given a comprehensive food plan and told him what to cut out (biscuits) and what to add in (veg).

The prescription has ended up helping the whole family: Lisa has now lost five stone and the children enjoy playing football with their father.

“I wouldn’t want to go back to the way I was,” says Lee. “Now I miss going to the gym.”