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Physical Activity - Consensus Risk Statement

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Physical Activity - Consensus Risk Statement

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Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions

1. 1 Moving Medicine, Faculty of Sport And Exercise Medicine, Edinburgh, UK

2. 2 Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, South Yorkshire, UK

3. 3 Sport and Exercise Medicine, Oxford University Hospitals NHS Foundation Trust Nuffield Orthopaedic Centre, Oxford, Oxfordshire, UK

4. 4 Stirling Physical Activity Research Knowledge and Learning Exchange (SPARKLE), University of Stirling, Stirling, UK

5. 5 Physical Activity for Health Research Centre, University of Edinburgh Institute for Sport Physical Education and Health Sciences, Edinburgh, UK

Correspondence to Dr Natasha Jones, Sport and Exercise Medicine, Oxford University Hospitals NHS Foundation Trust Nuffield Orthopaedic Centre, Oxford, Oxfordshire, UK; natasha.jones{at}ouh.nhs.uk

Abstract

Introduction The benefits of physical activity for people living with long-term conditions (LTCs) are well established. However, the risks of physical activity are less well documented. The fear of exacerbating symptoms and causing adverse events is a persuasive barrier to physical activity in this population.

This work aimed to agree clear statements for use by healthcare professionals about medical risks of physical activity for people living with LTCs through expert consensus. These statements addressed the following questions: (1) Is increasing physical activity safe for people living with one or more LTC? (2) Are the symptoms and clinical syndromes associated with common LTCs aggravated in the short or long term by increasing physical activity levels? (3) What specific risks should healthcare professionals consider when advising symptomatic people with one or more LTCs to increase their physical activity levels?

Methods Statements were developed in a multistage process, guided by the Appraisal of Guidelines for Research and Evaluation tool. A patient and clinician involvement process, a rapid literature review and a steering group workshop informed the development of draft symptom and syndrome-based statements. We then tested and refined the draft statements and supporting evidence using a three-stage modified online Delphi study, incorporating a multidisciplinary expert panel with a broad range of clinical specialties.

Results Twenty-eight experts completed the Delphi process. All statements achieved consensus with a final agreement between 88.5%-96.5%. Five 'impact statements' conclude that (1) for people living with LTCs, the benefits of physical activity far outweigh the risks, (2) despite the risks being very low, perceived risk is high, (3) person-centred conversations are essential for addressing perceived risk, (4) everybody has their own starting point and (5) people should stop and seek medical attention if they experience a dramatic increase in symptoms. In addition, eight symptom/syndrome-based statements discuss specific risks for musculoskeletal pain, fatigue, shortness of breath, cardiac chest pain, palpitations, dysglycaemia, cognitive impairment and falls and frailty.

Conclusion Clear, consistent messaging on risk across healthcare will improve people living with LTCs confidence to be physically active. Addressing the fear of adverse events on an individual level will help healthcare professionals affect meaningful behavioural change in day-to-day practice. Evidence does not support routine preparticipation medical clearance for people with stable LTCs if they build up gradually from their current level. The need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms. As part of a system-wide approach, consistent messaging from healthcare professionals around risk will also help reduce cross-sector barriers to engagement for this population.

physical activity

consensus statement

noncommunicable diseases

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Introduction

The International Society for Physical Activity and Health identified the healthcare sector as one of the eight best investments to combat global population inactivity. 1 2 Consequently, there is much interest in the UK and globally on using healthcare effectively and efficiently to promote physical activity. 3 The translation of this public health objective into clinical practice is notoriously challenging. Barriers are complex and multifactorial. Healthcare professionals cite a lack of the knowledge and skills required to reassure and motivate people with long-term conditions (LTCs) who are concerned that physical activity may aggravate their symptoms or even cause sudden death. 4-7

In their recently updated physical activity guidelines, the WHO highlighted increasing inactivity levels globally and updated public health recommendations. 8 They explicitly recommend physical activity as beneficial for adults with LTCs, 8 recognising that inactivity levels double in those groups. 9 The WHO Guideline Development Group rated adverse events as critical to clinical decision-making on physical activity. It commissioned an umbrella review reporting on adverse events around physical activity for adults in general, including pregnancy and post partum. 8 However, they excluded evidence reporting on clinical populations with the rationale that the data cannot be generalised to the broader population. 10 They did look specifically at the benefit to some clinical subgroups (cancer, HIV, hypertension and type 2 diabetes mellitus), but data about risk is less well defined and limited to broad comparatives. The WHO concluded that for all people, doing some physical activity is better than none. Medical clearance is generally unnecessary, provided the amount and intensity of physical activity are increased gradually. 8 They recommend people who develop new symptoms should seek medical advice but do not clarify what that advice should be or how it relates to risk.

Epidemiological studies show that multimorbidity is common (62% in the over 65's and 81% in the over 85's) and constitutes most routine clinical presentations. 11 Projections suggest that in the UK, complex presentations of individuals with four or more LTC will double by 2032, emphasising the importance of designing services to support the management of these people. 12 The literature about physical activity in LTCs is predominantly condition-specific (see online supplemental file 1). Previous guidelines and consensus statements on risk have also focused on adverse events in defined conditions making recommendations challenging to implement in a multimorbid population.

In summary, public health bodies and clinical guidelines are clear that physical activity should be central to almost all LTC management. However, a barrier to this is particular patient concerns surrounding risk, which generally relate more to their symptoms than their conditions. As a result, it is unclear how healthcare professionals should address physical activity or share relevant information during routine healthcare interactions. This consensus statement aims to address this evidence gap, to clarify the fundamental safety considerations that will inform the conversations on physical activity between healthcare professionals and symptomatic people with LTCs. It will form a bridge between clinical practice guidelines, public health guidelines and people's lived experience to address valid concerns that increasing physical activity might be unsafe or worsen their symptoms.

Aims

The aim of this project was to agree clear statements, through expert consensus, about the medical risks of physical activity for all adults, irrespective of age, living with one or more LTC. These statements are for healthcare professionals to support them during clinical practice.

It will address these commonly encountered questions:

Is increasing physical activity safe for people living with one or more LTC?

Are the symptoms and clinical syndromes associated with common LTCs aggravated in the short or long term by increasing physical activity levels?

What specific risks should healthcare professionals consider when advising symptomatic people with one or more LTC to increase their physical activity levels?

Methods

This is a multistage study with four discrete but related stages, each involving separate multidisciplinary working groups (see table 1). Table 2 demonstrates group roles and recruitment strategies. A complete list of contributors is in online supplemental file 2. This consensus statement has been developed according to the Appraisal of Guidelines for Research and Evaluation tool 13 and will be reviewed in 5 years unless advances in light of new or emerging scientific evidence prompt an earlier update.

Stage 1: preparation

The preparatory stage aimed to understand the opinion and perspectives of healthcare professionals and people living with LTCs on the risks of physical activity and how to address them during routine healthcare visits. Full details of the preparatory stage are in online supplemental file 3.

Patients and the public

We incorporated results from two related but discrete projects to inform our understanding from the patient and public perspective.

1. Patient and public involvement project to explore service users' experiences and views on how the National Health Service could better support their needs. 7

2. A national consultation with 361 members of the public led by The National Centre for Sport and Exercise Medicine at Sheffield Hallam University in collaboration with Sport England. This related piece of work helped further inform our understanding of patient preferences and successful approaches to improving physical activity support for people with LTCs. 14

Practitioners

We undertook an open question survey of the practitioner group to better understand risk perception in clinical practice, including barriers and facilitators to implementing and disseminating recommendations.

Stage 2: rapid evidence review

We undertook a rapid review of the literature to establish what is known about the risks of physical activity in people with LTCs. This type of review 'aims to assess what is already known about a policy or practice issue, using systematic review methods to search and critically appraise existing research''. 15

The rapid review aimed to provide an overview of existing guidelines and/or recommendations that address the risks of physical activity for people with LTCs, including:

1. What has previously been done to understand the associated risks?

2. What conclusions or consensus were reached?

3. How were conclusions or consensus reached?

The methods and full search strategy are in online supplemental file 1.

Stage 3: steering group meeting

The terms of reference for the steering group were to agree on core messages, review contraindication advice, develop consensus statement format, identify clinical priorities, approve statement development plan and ratify the delphi protocol.

The steering group appraised the results from the preparation phase and evidence review before a face-to-face workshop in November 2019. The meeting focused on the results of the preparation phase and evidence review, followed by a group discussion focussing on the terms of reference above.

Following the meeting, we reviewed the evidence base and recategorised it into a symptoms/syndrome format. In addition, we extended the literature review to address areas of specific clinical concern identified by the steering group. We then drafted consensus statements reflecting the outcomes of the steering group meeting. The draft statements and updated evidence summaries were then shared with the steering group via email for free-text comments and statements modified accordingly. We developed an online survey testing the content, structure, hierarchy of information and wording of the consensus statements. We piloted the survey with six healthcare professionals not involved in the project to ensure clarity, feasibility, and comprehensibility.

Stage 4: delphi study

We used a modified online version of the Delphi process 16-19 following the Conducting and REporting DElphi Studies guidelines. 18 Online survey rounds used the commercial software 'SurveyMonkey'. 20 Target completion time was below 30 min. Level of agreement used a scale of 1 (strongly disagree) to 6 (strongly agree) with space for free-text comments and suggestions where appropriate.

If invited participants did not reply to the initial contact, we checked the contact details and made one further effort. For the second and third phases, participants were invited by email. Reminders were sent out for non-responders at 2 weeks, 1 week and 2 days before survey closure. We took implied consent from the willingness to complete the survey. No participants stood to gain financially or otherwise from decisions taken in the delphi study.

Between phase feedback

We prepared individualised feedback for participants following each phase, which compared their response to each question with the group average. We presented a summary of free-text responses with associated modifications to each statement. The Delphi group received the supporting evidence summaries alongside each statement in the survey, and their recommendations informed the evolution of these summaries.

We maintained communication with participants through a project administrator to avoid imposing any opinion bias from the authorship group. 21

Pre-defined consensus criteria

In keeping with described methods, 17 21 satisfactory agreement for phase 1 required both:

We removed questions meeting these criteria for the second phase of the delphi. Questions with an average score >80%, but with one or more participants scoring 1-3, were interrogated for free-text feedback.

In phase 2, agreement was further stratified with >80% high agreement, satisfactory agreement range between 60% and 80%.

The study protocol included a potential third round of the delphi for items not achieving satisfactory agreement. This eventuality would require participants to vote on potential solutions. This approach facilitates timely progression and mitigates risks from survey fatigue. 22

Results

In this section we report results by study stage followed by the consensus statements themselves.

Stage 2: rapid evidence review

Seventy-nine relevant reports (reviews, consensus statements, position statements or guidelines) were reviewed, with findings summarised for review at the steering group workshop. See online supplemental file 1 for full rapid evidence review results.

There is considerable heterogeneity around reporting of risk and limited reporting of adverse events. In addition, variability exists within and between LTCs regarding what has been done and the specificity of recommendations or guidance.

Few studies commented on adverse events of physical activity as a primary outcome, with the majority primarily reporting the benefits of physical activity and/or exercise and only some addressing associated risks. There is heterogeneity in the nature of physical activity included in different studies (such as mode, frequency and intensity of physical activity), the specificity of adverse event reporting and inclusion/exclusion criteria for each study. In studies that did not comment on adverse events, it was not always clear whether this meant there were none or if this was not reported as an outcome. These limitations reflect the heterogeneity of LTCs, the variety of symptoms that people may experience and the broad clinical context to which this statement applies.

The evidence base on the risk of physical activity for people with LTCs is almost exclusively presented by condition rather than by symptoms. This may reflect leadership and ambition by condition-specific organisations. Nevertheless, where studies report adverse outcomes, they refer to aggravation of the symptoms of LTCs such as fatigue, breathlessness, chest pain, palpitations, dysglycaemia and so on. Therefore, this consensus statement needed to extrapolate symptom-specific data from disease-specific literature and provide clinical consensus on the generalisability of these findings across/to multimorbidity.

Despite this, the evidence consistently reports that the benefits of physical activity outweigh any potential risks, except where explicitly contraindicated. A person-centred approach is essential, with the understanding that there is an injury risk that applies to the whole population, that tolerance of physical activity will vary with symptom severity and that supervision may be appropriate or necessary.

Stage 3: steering group meeting

Box 1 shows summary recommendations from the steering group meeting. Following advice from the steering group, we drafted statements for testing during the Delphi.

Summary recommendations from the steering group meeting

Agree core messages:

Inactivity poses a high risk to health.

Physical activity recommendations should consider functional level, symptoms, individual preference and social confidence.

Address fears related to physical activity.

The benefits outweigh the risks.

Safety messages should include contraindications.

Aim to safely get all patients more active or maintain healthy levels of activity.

Understanding normal physiological responses to exercise helps individuals to identify if they have a problem.

Review contraindication advice:

To ensure a safe approach to initiating activity, inactive people should increase activity levels gradually.

People with unstable medical conditions require investigation.

Fear of adverse events is a common barrier for patients and professionals.

Safe advice should include recommendations on symptoms to look out for and where/how to report them.

Develop consensus statement format:

Focus on risks, not benefits.

Follow a symptom/syndrome-based rather than diagnosis-based approach.

Focus on self-directed physical activity.

Maintain a person-centred approach to increasing physical activity.

Identify clinical priorities:

Symptoms to address: musculoskeletal pain, fatigue, breathlessness, cardiac suggestive chest pain, palpitations.

Syndromes to address: cognitive impairment, dysglycaemia, falls and frailty.

Stage 4: delphi

Qualitative feedback and subsequent statement evolution are presented in online supplemental file 4. Twenty-eight participants completed the Delphi study in full (see figure 1). The Delphi recorded high levels of agreement overall (see table 4). Two symptom statements that met agreement criteria in phase 1 (palpitations and falls and frailty) did not require entry into phase 2. Despite meeting agreement criteria in phase 1, we re-entered headline statements 1 and 2 into phase 2 for feedback following formatting changes.

Similarly, we retested the dysglycaemia statement due to substantial rewording. Following phase 2, qualitative feedback informed minor wording edits to the statements. Phase 2 achieved consensus across all domains, so we did not require a third delphi phase.

Consensus statements

We provide five 'impact statements' that every healthcare professional should know about physical activity in people with LTCs. Following this are eight symptom/syndrome-based statements supported by a summary of the relevant evidence base. Figure 2 provides an infographic summary of the results.

Impact statements

The benefits of physical activity far outweigh the risks

Physical activity is safe, even for people living with symptoms of multiple LTCs. Regular physical activity, in combination with standard medical care, has an important role in the management and prevention of many LTCs.

The risk of serious adverse events is very low, but that's not how people feel

People with LTCs are often fearful of worsening their condition or experiencing potentially undesired consequences from physical activity. In fact, when physical activity levels are increased gradually, the risk of serious adverse events is very low. Well informed, person-centred conversations with healthcare professionals can reassure people and further reduce this risk.

It is not as easy as just telling someone to move more

Successful opportunistic brief advice helps build motivation and confidence to become more physically active. This can be consolidated at further healthcare visits to support lasting behaviour change. Advice from healthcare professionals should consider the concerns of individuals and their carers, as well as individual preference, symptoms, functional capacity, psychosocial factors, social support and environmental considerations.

Everyone has their own starting point

Everyone has their own starting point, depending on their current activity level. Help people identify where they are and agree a plan to begin there and build up gradually to minimise the risk of adverse events.

Advise people to stop and seek medical review if...

they experience a dramatic increase in breathlessness, new or worsening chest pain and/or increasing glyceryl trinitrate requirement, a sudden onset of rapid palpitations or irregular heartbeat, dizziness, a reduction in exercise capacity or sudden change in vision.

Symptom/syndrome statements

Musculoskeletal pain

For people who experience musculoskeletal (MSK) pain as part of their medical condition, physical activity will not increase pain in the long term. A temporary increase in pain levels is common when starting a new physical activity, until the body adapts, and people should be counselled to expect this. There is no evidence to suggest this pain correlates with tissue damage or adverse events in the absence of new injury (acute fracture/acute soft tissue injury).

Reported evidence demonstrates that, regardless of disease severity, age, pain or level of function, physical activity (aerobic, resistance or range of motion and land or water based) is likely beneficial for reducing pain and improving function in osteoarthritis. 23 24 Reported adverse effects are rare in studies with a physical activity component and usually relate to increased MSK pain with the physical activity intervention. 25-29 Activity modification should be considered during symptomatic exacerbations, or if the activity significantly worsens pain. 30 Studies of physical activity interventions in inflammatory arthropathies refer to minor MSK events, with no serious adverse events. 31-34 There are limited data about adverse events in studies of people with fibromyalgia, 35 36 however some people experience increased pain sensitisation in the short term, 37-42 which should be addressed as part of their holistic management.

Fatigue

Regular physical activity helps reduce fatigue and improves well-being and sleep. A temporary increase in fatigue is commonly experienced when starting a new physical activity until the body adapts. People should be counselled to expect this and advised to build up activity gradually. People experiencing fatigue related to chronic fatigue syndromes may benefit from specialist advice.

Increased sedentary behaviour is associated with higher levels of fatigue. 43 Adults who are more physically active report better overall well-being 44 45 and improvements in well-being domains. 46 Physical activity interventions are beneficial for fatigue in a broad range of long-term medical conditions, including rheumatoid arthritis, systemic lupus erythematosus, coronary heart disease (cardiac rehabilitation), inflammatory bowel disease, sarcoidosis, fibromyalgia and multiple sclerosis, 47 and are associated with the greatest overall improvement in cancer-related fatigue (especially when compared with pharmacological treatments). 48

Shortness of breath

It is normal for all people to feel more breathless when increasing their activity level. The balance of evidence suggests that the risk of adverse events in breathless people when doing physical activity is very low. People should be counselled individually to gradually increase physical activity, taking into account their severity of symptoms and fear of breathlessness.

Shortness of breath in chronic obstructive pulmonary disease (COPD) can result in progressive avoidance of physical activity 49 and worsening breathlessness due to deconditioning. Reduced activity level with increasingly severe breathlessness is an important predictor of mortality. 50 There are very few reported general contraindications to physical activity in individuals with COPD provided the particular activity is tolerated, comorbidities considered and recommendations individualised. 51 52 Increased shortness of breath, muscle cramp and soreness have been reported in physical activity interventions, especially at the beginning of the intervention. 53 The weight of evidence in this area is within pulmonary rehabilitation, 54 55 and although not universally reported, adverse events are rare, 54 including after exacerbations of COPD. 56 The physiological benefits of physical activity in heart failure are well reported 57 and is associated with reduced hospital admission and reduced all-cause and cardiovascular mortality in people with heart failure after adjustment for prognostic predictors. 58 Regular physical activity is associated with fewer adverse events in those with both preserved and reduced ejection fraction compared with sedentary groups. 57 In stable asthma, physical activity is not associated with adverse effects or exacerbation of symptoms, and no severe adverse events have been reported. 59-61 However, good asthma control and preventative strategies are important, as bronchospasm can occur.

Cardiac chest pain

The long-term benefits of increasing regular physical activity far outweigh the temporary, slight increased risk of adverse events even in those experiencing exertional chest pain as a result of ischaemic heart disease (angina). This risk increases with advancing age and exercise intensity, but overall remains very low. People should be counselled individually to gradually increase physical activity, taking into account severity of symptoms and fear of cardiac chest pain. Exercise is a good treatment option for stable angina to stimulate angiogenesis. However, increasing frequency and severity of angina should prompt a medical review with no further increase in physical activity.

In the 6 weeks after an acute cardiac event or cardiac surgery, all physical activity advice should be delivered by specialist services and outside of this document's scope. There is an increased risk of an acute cardiac event in previously sedentary individuals with known cardiovascular disease who undertake unaccustomed vigorous intensity exercise. The increased risk is present both during the activity and for 1-2 hours afterwards. However, the absolute risk of a cardiovascular event during physical activity is very low. The incidence of sudden cardiac death has been reported as 1 in every 1.5 million episodes of vigorous physical activity in men 62 and every 36.5 million hours of moderate/vigorous exertion in women. 63 Reports suggest a 6-17 times increased risk of non-fatal acute myocardial infarction and sudden cardiac death during vigorous-intensity physical activity, compared with being sedentary. 62 64 This risk reduces as physical activity levels are increased and cardiovascular fitness improves. 65 It is essential that levels of physical activity are increased gradually.

Until controlled by appropriate medical management absolute contraindications to physical activity include recent acute cardiac event or ECG changes suggesting significant ischaemia, unstable angina, uncontrolled dysrhythmia causing symptoms or haemodynamic compromise, severe symptomatic aortic stenosis, acute pulmonary embolus or pulmonary infarction, acute myocarditis or pericarditis, suspected or known dissecting aneurysm and acute systemic infection. 66

Palpitations

An increased awareness of the heartbeat is normal during physical activity but can be frightening. Physical activity is contraindicated in people with symptomatic and untreated cardiac tachy-arrhythmia or brady-arrhythmia. Appropriate medical management should be established prior to recommending physical activity. Individuals with controlled atrial fibrillation (AF) benefit from regular physical activity, which should be started gradually.

With any perception of sudden onset or unusual change in heart rate, individuals should review how they are feeling and consider slowing down or pausing activity to let this settle. Physical activity can have a positive impact on AF both before and after its onset, although the optimal recommended physical activity prescription has not yet been defined. 67 Regular physical activity is associated with a lower risk of all-cause mortality in patients with AF, with no serious adverse events reported. 68 69

Dysglycaemia

The benefits of physical activity outweigh the risks in both type 1 and type 2 diabetes. There is a risk of short-term dysglycaemia with physical activity. Hypoglycaemia is the most common adverse event associated with physical activity in people with any form of diabetes treated with insulin or insulin secretagogues. This can be recurrent if not managed appropriately. Guidelines are available to help reduce the risk of hypoglycaemia. Evidence suggests that the overall risk of severe hypoglycaemia is not increased in those who are more physically active. People with diabetes should be made aware that high intensity physical activity can cause a rise in blood glucose and offered strategies to combat this.

People with type 1 or type 2 diabetes should not start physical activity if they feel unwell or have had an episode of hypoglycaemia within the previous 24 hours. 70

Type 1 diabetes

Hypoglycaemia is rare but reported as an important adverse event. 71-73 People should have their blood glucose monitor with them and be vigilant with monitoring, carry diabetes identification and have a carbohydrate available. 74 There may be increased risk of hypoglycaemia for 24 hours after exercise including risk of nocturnal hypoglycaemia, especially with afternoon activity. 75 People should not start physical activity while ketones are abnormal, and the underlying cause should be found. 76 Ketones may rise in endurance exercise, without a significant rise in serum glucose. After vigorous physical activity, hyperglycaemia may occur, so caution regarding overcorrection (potentially leading to hypoglycaemia) is required. Those with advanced neuropathy, autonomic dysfunction, end-stage renal failure or severe proliferative/non-proliferative retinopathy may require specialist advice.

Type 2 diabetes

There are very few contraindications to physical activity in people with type 2 diabetes. 77 Coexisting comorbidities should be considered. People taking insulin or insulin secretagogues have an increased risk of hypoglycaemia with physical activity. No significant adverse effects were reported in a systematic review of randomised controlled trials in people with type 2 diabetes undertaking physical activity interventions (aerobic, fitness or progressive resistance training) compared with inactive control groups. 78 Minor adverse events include MSK symptoms and skin irritation. 79 While those with peripheral neuropathy should be closely monitored for complications, they are no longer advised to avoid weight-bearing activities. 80 Risk of skin breakdown should be considered, and well-fitted footwear that distributes load evenly is beneficial. 79 No increased risk of falls, pain or neuropathic symptoms has been demonstrated in individuals with diabetic peripheral neuropathy undertaking weight-bearing activities.

Cognitive impairment

The benefits of physical activity in people with cognitive impairment far outweigh the associated risks. Strategies to maintain motivation, engagement and safety are important and people will often benefit from support from others. Strategies should consider level of function, stage of disease, communication ability (including visual and hearing impairment), preferred environment, risk of falling and other health conditions.

Reports of serious adverse effects in physical activity intervention studies are rare in people with cognitive impairment. While most report no serious adverse events, 81 82 others include falls, MSK pain and chest pain after physical activity. 83-85 Despite this, strength and functional training has been associated with reduced risk of falls in those with mild-moderate cognitive impairment. 86 Support and supervision may be required due to cognitive impairment, balance, gait and proprioception, 30 87 so appropriate equipment and safety are important, and participation may be limited by motivation, emotional control, orientation and impaired judgement.

Falls and frailty

Frail, inactive people have much to gain from increasing physical activity levels and building strength and balance, including those with osteoporosis. Even small improvements in strength and balance can reduce a frail individual's risk of falling and improve their confidence. Recommendations for physical activity should be tailored to the functional and cognitive capacity of each individual. This can be further supported by environmental aids and adaptation, such as seated exercise plans, and it may be helpful for physical activity to be accompanied.

Fear of falling is a common concern for both patients and carers, both in the community 88 and in hospitals. 89 Falls are a common cause of morbidity and mortality. 90 Evidence from a recent systematic review demonstrates that physical activity reduced the rate of injuries from falls, including injuries requiring medical care or hospital admission. 91 A large study of physical activity interventions for falls prevention in the community mainly reported non-serious adverse events (commonly MSK) and two serious adverse events. 92 No serious adverse outcomes were reported in a systematic review of falls prevention classes in residential care. 93 Although adverse event reporting in physical activity interventions is highly variable, a systematic review and meta-analysis of frailty management strategies 94 reported that, although physical activity interventions were associated with higher rates of adverse events than other interventions, overall rates of serious adverse events (hospital admission, death, acute myocardial infarction and fracture) were lower. Non-severe events included MSK issues, exacerbation of osteoarthritis, falls, fatigue, skin rash and vertigo.

Discussion

This study aimed to develop, through expert consensus, clear statements about the medical risks of physical activity for people living with LTCs for use by healthcare professionals. Five 'impact statements' conclude that (1) for people living with LTCs, the benefits of physical activity far outweigh the risks, (2) despite the risks being very low, perceived risk is high, (3) person-centred conversations are essential for addressing perceived risk, (4) everybody has their own starting point and (5) people should stop and seek medical attention if they experience a dramatic increase in symptoms. In addition, eight symptom/syndrome-based statements discuss specific risks for MSK pain, fatigue, shortness of breath, cardiac chest pain, palpitations, dysglycaemia, cognitive impairment and falls and frailty.

Previous recommendations around the risk of prescribing physical activity in clinical practice have focused on cardiovascular risk, including the risk of sudden death. 65 95-98 This risk is low in both the general population and people living with LTCs, although the latter is less well described. 62 63 99 100 Despite this, fear of adverse events and worsening symptoms remains a significant barrier for people with LTCs to building self-efficacy and initiating successful behavioural change. 5 6 101

Preparticipation algorithms aim to help risk stratification and improve continuity between the health and physical activity and sports sectors. 96-98 102 However, substantial limitations exist to the utility and effectiveness of preparticipation screening tools in the effort to balance appropriate risk identification and avoid excessive physician referrals. 66 103 Since the risk of sudden death and serious adverse events to inactive people is minimal if physical activity is initiated at an appropriate level and then increased gradually, 65 95 100 we support the WHO recommendation that routine medical screening of people with LTCs is unnecessary. 8 In the event that individuals present to healthcare professionals with symptomatic concerns, successful behavioural change is unlikely unless they feel their particular concerns have been adequately addressed. 29

A challenge for this study is that the risk of physical activity-related adverse events in people living with LTCs is seldom reported and poorly quantified. Much of the relevant literature is condition-specific, addressing the benefits of physical activity and heterogeneously reporting adverse events as secondary outcomes. 100 The relationship between risk and clinical symptoms or syndromes is not transparent, so expert clinical consensus has been relied on to interpret this data. A limitation in the scope of this statement is that the list of medical conditions covered is not exhaustive. For instance, we do not include chronic fatigue syndrome and long COVID-19 since evidence on physical activity risk is limited and actively evolving in these areas. We cannot be sure that our symptom-specific statements translate effectively to clinical practice and subsequently to people living with these conditions. This is an important area for future research. Identifying safe and scalable strategies in healthcare to support sustainable behavioural change in the day-to-day lives of inactive people with LTCs will be a powerful asset to population approaches on physical activity. 1

Operationalising effective physical activity advice in routine healthcare is a challenge in the UK and other parts of the world. 104 105 Despite a willingness from patients to receive advice from trusted healthcare professionals, 106 support for patients around physical activity in preventing and managing LTCs remains inadequate. 107 Although healthcare professionals generally feel physical activity is important, a disparity is observed between intentions to engage people with LTCs in conversations on physical activity and confidence in their skills and knowledge. 108-110 This consensus statement will help support healthcare professional uncertainty on specific physical activity advice around risk for particular LTCs. 111 112 Providing succinct information in an accessible format will support time-sensitive conversations in clinical practice. 109 111 113 To support this aim and improve dissemination and accessibility, we will present our results in an open-access interactive format on the 'Moving Medicine' initiative website. 104 114 115 This website hosts a range of practical, person-centred consultation tools to support healthcare professionals having conversations on physical activity with people living with LTCs in clinical practice. This approach is in keeping with the WHO recommendation to deliver 'practice-based evidence' to narrow the gap between research and impactful public health initiatives. 116

In England, this consensus statement forms part of a broader programme of work led by Sport England, Public Health England and the Royal College of General Practitioners and wider partners to improve the physical activity experience for people living with LTCs. Sport England will, in collaboration with others, explore how this consensus statement can support the removal of systemic physical activity barriers for people living with LTC's. This includes encouraging discussions with a range of partners, including the physical activity and leisure sector insurers, and supporting a review of pre-participation protocols used by health, physical activity and sport partners, including the need for medical clearance. In addition, FSEM, Sport England and the Richmond Group of Charities, alongside others, will work together to consider how we use the statements to challenge patient's perceptions about risk and physical activity including evolving them into public-facing resources that empower people's decision making and connect to wider support.

We recommend research and evaluation into the feasibility, acceptability and efficacy of implementing these statements in healthcare. Can these statements improve the knowledge and confidence of healthcare professionals to empower people with the knowledge of what symptomatic change requires medical attention? Subsequently, understanding how best to promote cross-sector integration to remove systemic barriers to physical activity participation for people living with LTCs is critical to population-wide success. We welcome further research into conditions not covered in this study and call for routine reporting of risk and adverse events in all physical activity studies of people living with LTCs.

Conclusion

For people living with stable LTCs, the far-reaching benefits of physical activity outweigh associated risks. We present five headline and eight symptom/syndrome specific statements to help healthcare professionals talk to people living with LTCs to address the commonly perceived fear of adverse events on an individualised basis.

We challenge recommendations that individuals with stable LTCs require medical clearance before autonomously increasing their physical activity levels. We suggest that routine preparticipation screening in this group poses an unnecessary barrier to self-directed physical activity and engagement with the physical activity, sport and leisure sectors. Our findings suggest that the need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms.

In isolation, better support from healthcare practitioners will not be enough to make substantial change to the physical activity levels of people with LTCs. We call for healthcare and related sectors to work together to provide continuity of advice and support through clear and consistent messaging. This consensus statement provides a starting point for developing a common language around the specific issue of risk from physical activity.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The original research of this study is the Delphi stage, which was conducted by the Faculty of Sport and Exercise Medicine authors. The research proposal was submitted to the UK National Health Service (NHS) Research Authority and Medical Research Council decision-making tool, which confirmed that NHS Research Ethics Committee review was not required. All participants of the Delphi and practitioner groups provided informed consent by agreeing to complete the surveys following a detailed description of what participation entailed. All Delphi participants are listed as collaborating authors.

Acknowledgments

We are grateful for the time, energy and commitment our stakeholder group have contributed to the inception and delivery of this project together with their commitment to future dissemination and cross-sector implementation: Suzanne Gardner and Sarah Ruane on behalf of Sport England; Andrew Boyd on behalf of the Royal College of General Practitioners; Mike Brannan and Jamie Blackshaw on behalf of Public Health England and Michelle Roberts on behalf of the Richmond Group of Charities.

Read the full text or download the PDF:

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Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions

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Introduction The benefits of physical activity for people living with long-term conditions (LTCs) are well established. However, the risks of physical activity are less well documented. The fear of exacerbating symptoms and causing adverse events is a persuasive barrier to physical activity in this population.

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Children and Young People Now - Article link

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Children and Young People Now - Article link

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'Riding the wave of Social Prescribing'

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By Liza Jarvis and Nicole Weinstein

Social prescribing is increasingly being offered to children and young people with mental health and other difficulties. Experts explain how it works and the difference it can make to young lives.

Social prescribing is not new; it has been delivered for many years here in the UK. But more recently there has been a significant expansion thanks to NHS funding for new roles in primary care, including social prescribing link workers.

While it has always been seen as a model that can help people of all ages, the focus to date was largely on adults with social prescribing for children and young people still in its infancy.

However, a decline in young people's mental health and a rise in social isolation since the pandemic has prompted the creation of a growing number of dedicated services for children and young people.

The term social prescribing is often misunderstood. It is essentially a non-medical approach that involves prescribing activities to help boost someone's health and wellbeing.

Schemes for children and young people involve social prescribing link workers working closely with young people, giving them time and space to work out what matters to them. They then work together to create a plan of support that recognises and builds on the young person's strengths and talents.

Family context

While the principles of social prescribing for children and young people are the same as for adults, there are some significant differences to be aware of. Work with young people must take into account their family context as well as issues relating to safeguarding, consent, confidentiality and the range of organisations that might be involved with a young person.

Importantly, link workers need youth work skills to be able to build relationships with young people and support them safely. Having a link worker who "gets it" is key to increasing positive outcomes for young people. Services that have attempted to expand existing adult provision without recruiting a link worker with youth work skills have tended to struggle.

Research by StreetGames and the University of East London found that referrals to children and young people's social prescribing services came from a wider range of professionals and organisations than traditional adult models. While 20 per cent of referrals were from GPs and other primary care services, other referrals were made by education, youth services, police, youth justice services or through young people referring themselves.

Social prescribing for children and young people has many benefits. It is part of the model of personalised care, which means it provides tailored support for a young person that is easy to access and based on what matters to the young person. It does not rely on a diagnosis and allows practitioners to be creative and work with young people of all ages and their families to identify support that truly meets their needs.

Social prescribing can support young people with a range of needs including mental health and emotional wellbeing - the most common reason for referrals, according to our research. It can also be used to address physical health problems such as diabetes, obesity and other long-term health conditions. It can help tackle social isolation and loneliness and often results in improved school attendance and educational attainment and increased use of local support services.

Social prescribing for children and young people can also have a preventative role, reducing the need for statutory or clinical services. It helps give young people and their families the tools they need to support themselves in the immediate and longer-term, leading to increased stability and resilience.

Partnership work is key to the successful delivery of social prescribing services with statutory services such as education, social care and health working closely with the wide range of services delivered by the voluntary and community sector.

Wider support network

Services for young people should include and involve key people in a young person's life. This may be their parents or carers or other trusted individuals who can help support the young person. Social prescribing should always be seen as part of a wider support network and not a standalone service.

Prescribed activities may include sport and physical activity, social activities or arts activities such as drama, dance and music. These may be group activities such as joining a club or individual activities like running or going to the gym. "Green" prescribing promotes the benefits of being in nature and can include pursuits such as gardening or growing vegetables in an allotment while "blue" social prescribing promotes the benefits of water-based activities such as surfing, paddle boarding and boating.

The difference social prescribing can make to young people's lives should not be underestimated. In some cases, it is life-changing. Through our work, we have seen young people's mental health and wellbeing improve to the point where they no longer need statutory services.

It can help prevent problems escalating as well as providing a useful step down from higher-tier services. Most importantly, young people tell us they have fun, feel happier and can take part in activities that enhance their lives.

The evidence for social prescribing is abundant but is largely based on adult provision. However, there is growing evidence of positive outcomes from youth social prescribing with research projects under way that will add to the evidence base for this exciting new field of work.

We are urging professionals to consider setting up a children and young people's social prescribing offer in their area.

The NHS's Additional Roles Reimbursement Scheme funded through primary care networks provides an opportunity to employ dedicated link workers. These are either employed directly by the primary care network or hosted by a voluntary and sector partner.

StreetGames founded the Social Prescribing Youth Network with the ambition that every primary care network in England should have at least one link worker dedicated to working with children and young people.

Growing network

The network continues to grow and now has more than 1,000 members, including link workers, voluntary and community organisations, social prescribing co-ordinators, commissioners, funders, GPs, youth workers, police officers, teachers and researchers.

We recognise there are still some challenges, including a lack of awareness of children and young people's social prescribing and the fact the social prescribing workforce is still mainly focused on adults.

Another key issue is an over-reliance on the voluntary and community sector to provide activities. Charities and others are often expected to deliver prescribed activities without the necessary funding streams in place.

Social prescribing can make a huge difference when delivered well. It is an intervention that not only saves money but reduces the need for services long term by creating a "kitbag" for young people to dip into when they need it most.

By Liza Jarvis, children and young people social prescribing lead, Street Games

The Social Prescribing Youth Network hosted by StreetGames provides access to free information, support and resources. Find out more and sign up at SPYN@streetgames.org

UK-WIDE
Socially prescribed surf therapy boosts young people's wellbeing

Social prescribing has opened the door to new activities - including surf therapy - being made available to young people to address mental and physical health issues.

The therapy, developed by The Wave Project, was piloted in Cornwall in 2010 and now helps 2,000 young people in 16 locations across the UK each year.

Wave Project founder and chief executive Joe Taylor has seen the difference it can make.

"One boy diagnosed with selective mutism began to talk freely again," he says. "He was on the water with his mentor and just started asking questions. We weren't expecting this hugely profound change."

The programme involves a six-week course of weekly surf lessons led by qualified surfing instructors with one-to-one mentoring support from trained volunteers.

Schools, social services, family services or GPs can refer young people aged between eight and 24 years who are at risk of mental ill health due to physical disabilities, learning disabilities or family issues involving domestic violence or trauma.

Evaluations have consistently shown improvements in confidence and self-esteem, with young people reporting feeling "calmer" and "more positive" about life.

An independent evaluation in 2015 found parents and referrers noticed improvements in young people's self-management and behaviour, both at home and school.

Alfie, aged 10, says the programme has helped with his confidence and making friends and that he felt "calm, playful and like himself" in the sea.

"While our goal is to improve children's wellbeing, the young person's objective is to learn how to surf," says Taylor. "The big takeaway for many children is the feeling of empowerment they get from knowing there are kind people out there who want to make time for them."

The course costs between £700 to £800 per child to run but funding can be a challenge. About 90 per cent of the Wave Project's funding is made up of grants from bodies like the Big Lottery Fund and Tudor Trust, donations and corporate sponsorship with only a small proportion from local authorities or the NHS.

Service level agreements exist in some areas, such as Cornwall - where the local authority contributes £150 for every child it refers - but only 40 per cent of referral partners contribute towards costs.

A reliance on fundraising in most areas limits the number of young people the charity works with.

Taylor says offering socially prescribed services can be "quite a poor deal".

"Charities are asked to accept referrals and work with people to improve their health but there's no money," he says.

"That's inevitably going to cause problems. If the NHS set aside funding to support charities with socially prescribed services so link workers had a budget, that would make a massive difference."
By Nicole Weinstein

Support includes service based in A&E

Youth charity No Limits provides a range of social prescribing services to children and young people across Hampshire.

In 2018, the charity launched its community-based social prescribing service, which connects 13- to 25-year-olds in Southampton with local groups and services that offer practical and emotional support for issues such as low mood, social isolation, anxiety, difficulties at school or getting into training and employment.

"We've built strong connections with local providers and can refer young people to sports and physical activities, youth groups, theatre or music groups, anger and stress management or counselling and peer support, to improve their quality of life and wellbeing," explains project manager for inclusion and support Michelle*.

To sign up for the service, young people, parents, schools, social services or GPs can access an online form. Over the course of six sessions, each young person receives an individual plan involving assessments, appointments, referrals, follow ups and wellbeing support.

One of the services young people are referred to is the Teen Safe House, a weekly support group for 13- to 19-year-olds with confidence and anxiety issues, where they meet to talk and take part in activities, such as making smoothies or playing games.

"Young people report reduced feelings of isolation, loneliness and anxiety and increased motivation to engage with support services and activities," says Michelle.

The charity also offers social prescribing services linked to 111, emergency care and child and adolescent mental health services (CAMHS). If a young person or parent calls 111 to report issues around low mood, anxiety, self-harm or suicidal thoughts, their call is first triaged and assessed for any immediate risk. Where appropriate they may then be referred to No Limits' 111 social prescribing service.

Similarly, No Limits youth workers who work in paediatric or adult emergency departments with young people who may have experienced violence, trauma, substance abuse or other issues can refer them to the emergency department social prescribing service while the CAMHS-based service launched in April this year.

Young people must give their consent to work with all three services, which then help them engage with local community groups.

An evaluation of the emergency department service by the University of Southampton and Solent University in May 2022 found 85 per cent of young people felt better about themselves, 78 per cent felt better about their future and 86 per cent agreed it had helped them think about their options.
*Surname withheld By Nicole Weinstein
7 top tips for setting up a social prescribing service from the social prescribing youth network

1. Ensure robust governance and accountability. When setting up a service make sure you have the right governance and accountability structures in place. Understand who you report to, who has ultimate responsibility for the scheme and who ensures you have the right standards and polices in place on issues like safeguarding, consent and confidentiality.

2. Focus on ethos. The scheme's design should reflect the evidence for community-centred and place-based ways of working to address inequalities and improve health and wellbeing. It should be fully inclusive with children, young people and their families involved in all aspects of design, delivery and evaluation.

3. Plan carefully. Take time to really understand what it is you want to do and how you want to do it, including how it fits with wider provision for children and young people. Be clear about your aims and how and where you want to deliver based on local evidence and knowledge.

4. Have a clear referral process. It is important to have a clear, easily understandable and accessible referral process. Understand that referrals for children and young people can come from multiple sources - not just the GP - and ensure you have the right systems in place to support this.

5. Recruit link workers with the right skills. When recruiting social prescribing link workers ensure there is a clear job description and person specification listing the competencies, qualities and experience required for the role, including specific skills needed to work with children and young people. Ensure there is a planned induction and regular supervision is available.

6. Gather data. Make sure there are agreed methods for collecting data for monitoring, evaluation and quality improvement work. Data gathering must comply with the General Data Protection Regulation (GDPR) and young people must be told how their data will be used.

7. Measure impact. Methods for monitoring outcomes should be established from the outset and must be appropriate for the needs of the children and young people accessing the service. This information should be used to help young people understand how much progress they have made and to help the service understand its impact in the wider community.

CHICHESTER
Service helps young people devise a plan based on their needs

Chichester Youth Connections is a social prescribing service for 13- to 19-year-olds experiencing low-level emotional health and wellbeing issues.

It was set up in May 2022 as a two-year pilot funded by Chichester District Council and local housing associations Hyde Foundation and Clarion Futures.

Since launching, the project, run by young person's social prescriber Clare Faulkner (pictured), has supported 15 young people who are experiencing anxiety, isolation or lack of confidence.

"Some young people recognise they need support but don't know where to turn for help," she says. "My role is to help them come up with a plan over several sessions.

"It could involve referring them to a sports or creative activity, or they may need counselling or careers advice. The aim is to help prevent a young person's needs escalating."

Jane*, aged 18, was referred by her GP after dropping out of college due to a chronic health condition and feeling socially isolated.

Since accessing the programme, she has attended organised social activities, had counselling, enrolled in a local arts programme and is exploring volunteering opportunities.

"My social prescriber Clare has played a massive role in helping me feel connected to my community," says Jane.

"Aside from being a friendly face to talk to, she has opened windows of opportunity. I think social prescribers are increasingly necessary to help young people flourish and find a sense of belonging."

The service is evaluated using the Meaningful Measures framework, used for assessing social prescribing services and other interventions with young people. This involves looking at wellbeing scores before and after the intervention.

One young person rated her level of concern over her new diagnosis of attention deficit hyperactivity disorder as four out of six when she first came to the service.

"In the follow up assessment, her score went down to one out of six," says Faulkner. "There was a significant change."

To sign up for the service, young people either self-refer through the Chichester Youth Connections website or agree to a professional or carer making a referral on their behalf.

GPs can signpost young people to the service through a direct link on the district council's adult social prescribing website.
*Name changed By Nicole Weinstein

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Social prescribing is increasingly being offered to children and young people with mental health and other difficulties. Experts explain how it works and the difference it can make to young lives.

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https://www.theguardian.com/society/2023/oct/22/calls-for-strategy-on-social-prescribing-in-england-amid-youth-mental-health-crisis - Guardian article linked to this report

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[It] has been a huge help for me. My anxiety was awful, I wouldn't leave the house or talk to people, my attendance was awful, I couldn't bring myself to go in. It's had such a positive impact on my life, I can do stuff now, my attendance picked up, I can go outside. [...] I never thought I'd come this far, from where I was to a college place.

Barnardo's service user supported by the Cumbria LINK social prescribing service.

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The Missing Link: social prescribing for children and young people

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This report examines the current evidence around the benefits of social prescribing for children and young people and brings it together with new research from Barnardo's services.

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Min Data Set Social Prescribing London PAHF meetin 06122023

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Whole system approaches to tackling inactivity – learning from good practice – LGPAP

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Before the pandemic, systems thinking and whole systems change was already being recognised as the means of addressing the stubborn social, environmental and economic challenges we face. These challenges, and particularly the challenge of health inequality, have now been intensified and systems chan…

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Physical Activity ‘The Miracle Cure’ in Action: Social Prescribing webinar

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Hear from those working to support physical health activities and social prescribing, on how being active can be considered a ‘miracle cure’ for preventing and managing a number of chronic conditions.

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Designing movement into physical activity

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Personalised care and social prescribing slides

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N071_13 Health_and Wellbeing Coach recruitment pack FINAL

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N070_13 Care Coordinator Recruitment Pack FINAL

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Office for Health Improvement and Disparities

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Community-centred practice: applying All Our Health

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The Public Health England (PHE) team leading this policy transitioned into the Office for Health Improvement and Disparities (OHID) on 1 October 2021.

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Health and Wellbeing Hubs: Delivering local services under one roof

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These case studies highlight the varied ways councils are working in partnership with the NHS and other local partners to introduce Health and Wellbeing Hubs.

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Social prescribing is not a new invention. For decades community navigators and wellbeing advisers in local government have used social prescribing to help tackle loneliness, improve mental health and more.

As conveners of place and local leaders who know their communities and the voluntary and community sector, councils have always sat at the heart of social prescribing. Through our role as social care and public health commissioners, we work with some of the most vulnerable residents and have a firm commitment to the health and wellbeing of our communities. We deliver a wide range of services which social prescribing link workers can refer people to - from parks and playing fields, to libraries, leisure centres, art galleries and museums.

Thinking creatively, investing in what already exists and joining up services will become increasingly important as we recover from the COVID-19 pandemic and the cost of living crisis increases the need for housing, debt advice and growing demand for mental health, social care and health services.

The pandemic has only served to highlight how crucial culture, leisure, parks and creativity is to people's lives. Many culture and leisure organisations responded with remarkable speed to the pandemic, adapting their services to deliver digital activity, wellbeing boxes and providing direct support to the most vulnerable. Harnessing innovation and the wealth of culture and leisure related social prescribing initiatives already being run will be crucial to meet the challenges facing communities and councils. I am proud to share some examples of these in this handbook. The case studies are a mix of examples identified prior to and during COVID-19, all remain relevant for the sector as we move into recovery.
Councillor Gerald Vernon-Jackson CBE
Chair of the Local Government Association Culture, Tourism and Sport Board

This handbook highlights the vital contribution culture, leisure, green spaces, and sport make to social prescribing. It shares inspiring case studies from across the country of councils using a range of innovative in person and digital models to deliver social prescribing initiatives to improve the health, wellbeing and care of individuals. The handbook explores the opportunities for councils and their partners to work together to expand the reach of their social prescribing offer, level up growing health inequalities, support communities affected by the rising cost of living and tackle the burden on social care and NHS services. The handbook builds on the LGA's publication Just what the doctor ordered, social prescribing - a guide for local authorities.

Rt Hon. Lord Howarth of Newport, Co-Chair, All-Party Parliamentary Group on Arts, Health and Wellbeing declared "the time has come to recognise the powerful contribution the arts can make to our health and wellbeing", in the Creative Health short report.

During the COVID-19 pandemic we witnessed first-hand how key community assets such as libraries, theatres and leisure centres responded rapidly to the needs of their communities. Alongside this local parks and open spaces provided solace to many.

Repeated lockdowns and social distancing saw the nation turn to home-based arts, fitness and cultural activities, with around 1 in 5 people increasing their arts activity engagement and 1 in 8 increasing how much they watched arts performances online, above usual pre-pandemic levels. Many culture and leisure organisations responded by providing digital activity such as online book groups, children's activities, exercise classes and streamed theatre performances. The reach of digital output during the pandemic was exceptional. Libraries Connected reported a 600 per cent increase in digital membership as well as a fourfold increase in the number of eBooks borrowed and Kingston Library Service reached on average 10,000 people for each of its online Rhyme Time sessions.

The pandemic fast tracked relationships in many areas, as councils, health, voluntary and community sector partners and community leaders worked together at speed to respond to the needs of their communities, especially for the most vulnerable and shielding residents. This included but was by no means limited to socially distanced deliveries of care packages, medical prescriptions and arts and crafts activities. As well as making phone calls to residents who were lonely or isolated and getting key public health messages and support out to communities via community leaders, where their reach was greater than the councils'. Norwich and Norfolk Festival Bridge were one of many arts organisations throughout the country who delivered creative packs to over 7,500 families, enabling children to access the benefits of creativity while away from school.

As we emerge from the pandemic and our communities face new challenges with the cost of living crisis, these relationships are more important than ever as we look to reduce health disparities amongst communities. This handbook will demonstrate how utilising sport and culture in social prescribing can make a powerful contribution towards improving and empowering the lives of individuals and can reap many wider benefits and will hopefully give you a blueprint for developing services in your area.

Social prescribing - also known as community referral, is a means of enabling health professionals to refer people to a range of local, non-clinical services. Essentially, itcan be described as the place where the NHS "meets" the community and its assets, as illustrated in figure 1.

Social prescribing suits a range of people including people with one or more long-term condition, people who need support with their mental health, lonely or isolated individuals and those with complex social needs. Individuals either self-refer or are referred by a GP or other health care professional to a social prescribing link worker. The link worker will meet with the individual to understand what they want and help them to come up with their own health and welfare plan. The conversation is about what matters to them rather than what's the matter with them. It may be straightforward advice - for example, access to housing support, financial advice or benefits. But it may also be that they feel isolated or lonely, that they are experiencing poor mental health and would welcome involvement in local community activities.

Councils are central to supporting social prescribing through their responsibility for:

shaping services to meet local needs

influencing wider social determinants of health such as housing or regeneration

tackling health inequalities

linking up local service provision

commissioning services for vulnerable residents such as social care and public health

funding and delivering a wide range of services, assets and facilities.

This direct interest in health and wellbeing outcomes and connection to wider services means councils are well-placed to take a leadership role in developing social prescribing and in benefitting from its results such as healthier, happier communities and lessening the burden on social care services.

Promising Approaches (2015) by Age UK found that individual support was vital in helping lonely people connect with their communities again. It was not enough to provide lunch clubs or walking groups, it was the individual input from link prescribers/community connectors that helps people to find what they need. The report also notes that social isolation as well as loneliness is an increasing challenge among older people and can be as detrimental to health as smoking and obesity. Isolation is correlated with depression and cognitive decline.

This is a welcomed investment but currently there are no plans to nationally fund the services that link workers make referrals to, such as community groups, arts and leisure services. This is problematic because many of these providers have been significantly stretched because of the pandemic and some are no longer operating. This means that local leaders from the NHS and councils need to come together with the voluntary, community sector to understand local need and co-develop suitable delivery models and local assets that align with what communities have said they need and want. In this way scarce resources and local knowledge will be put to best use.
Figure 1

What does good social prescribing look like?

Social prescribing is most effective when internal and external senior stakeholders (both at political and at officer level) are committed and there are strong partnerships for delivery. Strong social prescribing initiatives often share the qualities highlighted in figure 2.
Figure 2

Holistic and co-ordinated: works seamlessly across a range of services from GPs to libraries, to offer a holistic approach to health and wellbeing that is about more than clinical needs. Link workers are embedded in communities and the Voluntary, Community, Faith, Social Enterprise sector (VCFSE)connect people to these groups and services. Link workers build trust among the individual being referred and the service provider, ensuring they are a right fit.

Strategic: identify strategic and commissioning opportunities to advocate for social prescribing. Quality standards are co-developed and agreed with strategic and delivery partners to achieve the best outcomes.

Engaged and empowering: involves, collaborates and co-produced with local communities.

Open and accessible: services used for social prescribing should be open to the public, not prescription-only, available to all ages from young to old and deliver the responsibilities under the Equalities Act 2010. Services are accessible, including supporting reasonable adjustments and offer activities in a range of models such as in person, hybrid and online, and avoid digital exclusion.

Funded: social prescribing schemes have a sustainable funding model. Costs attached to using community services, such as libraries, arts and culture services and venues are taken into consideration. Individuals delivering social prescribing services are appropriately trained and equipped to meet the needs of people accessing services.

Evaluated: evaluation and monitoring mechanisms are implemented into the design of programmes in order to refine the programme, improve outcomes for individuals and make the case for future funding.

There are a range of social prescribing models to consider. This could be a hub model where people are referred into a central point for information and support, or one where link workers operate individually across different community areas.

A statement from Shropshire Council evaluation of social prescribing (2017-18) declares "the initial appointment with the social prescribing advisor has changed my life. I am now fitter and have lost two stone in weight. I feel more energetic and healthier".

Social prescribing, the arts, culture, sports, leisure and parks services all make a significant contribution to addressing a wide range of local and national policy priorities. Studies point to improvements in quality of life and emotional wellbeing, mental and general wellbeing, improvement in levels of depression and anxiety and job prospects. Some of the policy areas they can make a direct impact on include:

levelling up: improving health and wellbeing, narrowing the gap in healthy life expectancy, strengthening communities through investment in activities that enhance physical, cultural and community led projects.

public health issues such as tackling obesity, reducing health inequalities, improving mental wellbeing and supporting people with long term conditions

delivering the NHS' personalised care agenda and reducing the demand on health and social care services, tackling long waiting lists, supporting people with long COVID.

Social prescribing remains high on the government and NHS' agenda. The Government's Levelling Up the United Kingdom White Paper makes reference to social prescribing. Specifically, it supports the ambition to narrow the gap in Healthy Life Expectancy (HLE) by 2030 and increase HLE by five years by 2035. (Levelling Up Mission 7).

The evidence of the benefits extends beyond health services to social care, skills and employment and public health to name but a few. This data can be incredibly helpful especially when engaging with NHS commissioners where there may be differences in organisational culture, priorities and language which can act as a barrier to securing investment and joint working. It can also help to open up wider conversations with public health and social care commissioners. For example, recent UK evaluations have reported the following benefits to the health sector:

Sixty per cent reduction in GP contact times in the 12 months following intervention compared to the previous 12 months

Twenty-five per cent reduction in A&E attendance in the social prescribing group, with a 66 per cent increase in A&E attendance by the control group

Seventeen per cent reduction in A&E attendance and seven per cent reduction in non-elective in patient stays were reported in the 12 months post intervention compared to the 12 months before it from the most recent evaluation report from the Rotherham Social Prescribing Service.

The benefits to primary care also include increased capacity because people with non-clinical needs are supported by link workers and community activities. For example, in the Alvanley Family Practice, patient numbers at the practice have gone up by 26 per cent in the last two years but the pressure on staff has gone down as a result of its Health Champions approach (see case study). GPs now see 12 patients per session and not 15. Leaving them more clinical time for patients.

While recent evaluation undertaken by Sheffield Hallam University (September 2020) found that 81 per cent of service users experienced positive change on at least one outcome measure ranging from improved wellbeing to skills development which could potentially lead to employment and/or improved job prospect. It showed that of the control group participating in social prescribing:

Forty-seven per cent of people felt more positive

Forty-six per cent of people made progress on work, volunteering and other activities

Thirty per cent of people made progress on money.

However, social value is not just about monetary worth or savings but also about the value that people place on the changes they experience in their lives. Where Social Return on Investment (SROI) is reported, it is usually greater than simple financial savings. A systemised review of social prescribing schemes by Helen J. Chatterjee et al (June 2017) reported the following multiple benefits:

increases in self-esteem and confidence, sense of control and empowerment

improvements in psychological or mental well-being, and positive mood

reduction in anxiety and/or depression, and negative mood

improvements in physical health and lifestyle

reduction in visits to general practitioners, referring health professionals and primary or secondary care services

provision to general practitioners of a range of options to complement medical care for a more holistic approach

increases in sociability, communication skills and social connections

reduction in social isolation and loneliness, support for hard-to-reach people

improvements in motivation and meaning in life providing hope and optimism acquisition of learning, new interests and skills.

Tips for success

1. How can social prescribing deliver on local priorities? Take the time to identify how social prescribing relates to local NHS and council priorities and how it can add benefit. This will help to make a persuasive argument for investment and partnership working across different service areas both within and external to the council.

2. What evidence and data supports this offer? Build a strong and well evidenced business case demonstrating the positive impact on individuals and the potential savings that could be made to over-stretched budgets. Public health teams hold a wealth of data insights and may be able to support the process.

3. What local structures are in place and where is your influence strongest? This could be the local health and wellbeing board, the Integrated Care System, Integrated Care Board, the Primary Care Networks (PCNs), public health team. Who do you need to influence?

4. How can you make the shift from a delivery partner to a strategic partner? Get creative! The All-Party Parliamentary Group on Arts, Health and Wellbeing's Creative Health report recommends appointing creative health champions to board or strategic positions to promote and encourage the use of the arts in health. Currently, 45 creative health champions are represented in trusts, councils and clinical commissioning groups.

Partnership working is key to building a rich local offer. Before embarking on your journey it is important to get a clear picture of:

Who are your local partners?

What are your communities' needs?

What are your local assets and where are they located?

What resources are available?

Which organisation is best placed to act as the primary social prescribing lead?

What model of social prescribing would work?

In this section we look at some of the challenges affecting partners, this will help to identify where you might be able to add value.

Social prescribing link worker: link workers act as a bridge between new and established community organisations, and the formal health and care system. Arrangements will vary across the area, some maybe part of existing schemes, employed within Voluntary, Community Social Enterprise (VCSE) organisations or directly employed by the PCN. Recent research shows that some link workers who are new in post, or not employed within wider organisations have struggled to find a role within the wider community response in the absence of established links into the community. Many link workers are also seeing the increased numbers of referrals by as much as 700 per cent in some cases because of the pandemic.

Integrated Care Systems (ICSs): are new partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area.ICSs are made up of the Integrated Care Board (ICB) and the Integrated Care Partnership (ICP). On 1 July 2022 under the Health and Social Care Act 2022 (April 2022) all 42 ICSs were put on a statutory footing and given responsibility for funding, performance and population health. Their purpose is to remove organisational barriers and encourage collaboration to tackle inequalities, enhance productivity, value for money and help the NHS support broader social and economic development. They are also tasked with tackling complex challenges such as improving the health of children and young people, supporting people to stay well and independent, acting sooner to help those with preventable conditions, supporting those with long-term conditions or mental health issues, caring for those with multiple needs as populations age and getting the best from collective resources so people get care as quickly as possible. The extent to which ICSs have developed varies across the country with some more established and with better partnership working in place then others, which may be a challenge for outside influencers. The term 'ICS' is also used to refer to the geographical area covered by the system. While strategic, at-scale planning is carried out at the ICS level, places will be the engine for delivery and reform at place and neighbourhood level. Each ICS covers a population size of 1-3 million and is not coterminous with council boundaries meaning more than one can fall into an ICS area.

Integrated Care Board (ICB): a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. They are accountable to NHS England for NHS spending and performance. ICBs have replaced clinical commissioning groups which have been abolished.ICBs are expected to work closely with all health and wellbeing boards in their area (those whose area coincides with or includes the whole or any part of the area of the ICB). Before the start of each financial year, each ICB and their partner must publish a five-year joint forward plan, setting out how they propose to exercise their function. These plans must describe any steps taken to implement relevant joint local health and wellbeing strategies. Each Health and Wellbeing Board (HWB) must be given a draft of the plan, or any revised plan, and be consulted on whether it takes proper account of each joint local health and wellbeing strategy.

Integrated Care Partnership (ICP): a statutory committee jointly formed between the NHS ICP and all upper-tier councils that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area.

Primary Care Networks (PCN):PCNs bring together groupings of local GP practices with other primary and community care organisations to join up health and care services at neighbourhood level. Serving populations of around 30-50,000 patients, PCNs are the channel for social prescribing link worker resources and in many cases will host the link worker service. The role of PCNs is to help general practice by using economies of scale, overcome barriers between primary and community services, and develop population health approaches. Some are still in development, but more mature networks are now able to deliver more joined up care for patients by developing multidisciplinary teams and recruiting additional roles to ease workload pressures.

Children and adults social care and p ublic health: falls under the responsibility of unitary and upper tier councils. Social prescribing schemes may already be run or funded by public health or social care and teams are likely to have developing or established relationships with ICSs, ICBs, PCNs, VCSE and link workers. Public health teams hold a wealth of population health insights and are responsible for developing the local Joint Strategic Needs Assessment (JSNA) and local Joint Health and Wellbeing Strategy (JHWS), which identify local needs and priority areas. Public health, children's and adults social care budgets are facing significant demands and funding pressures.

Health and Wellbeing Board: a statutory committee of councils with responsibility for public health. It brings together NHS, public health, social care and Healthwatch to strategically plan health and wellbeing services based on the JSNA and JHWS. In some areas they have been subsumed by ICSs, in other areas they have retained a lead role within the new health landscape. District councils are not statutory members but in many areas are often part of the wider membership.

Voluntary, Community and Social Enterprise sector (VCSE): The sector is involved in the roll-out of social prescribing with some link workers employed by VCSE organisations and some organisations acting as a provider of social prescribing services. Medium sized organisations are likely to hold key relationships both across the sector and with the NHS and the wider public sector. The majority of VCSE groups and organisations are very small and lack the resources and capacity to proactively seek out referrals and join up locally. Furthermore, the differing size footprints between ICS and the VCSE sector and the sheer number of PCNs is making it challenging for some organisations to engage with health partners.

The Mayor of London wants the VCSE to be regarded as an equal partner in the design and delivery of services, is adequately funded, and has the necessary tools to be central to the growth of social prescribing. With this in mind, the Mayor is providing grant funding to London Plus to deliver a VCSE social prescribing network. It connects a variety of stakeholders, shares models and best practice, helps to improve outcomes, influences across the NHS, highlight gaps in services and funding and explores challenges and solutions to tackling health inequalities. The network produces free resources including a FAQ with details of the things needed to set up an organisation to deliver social prescribing activities.

Providers: some councils have become the social prescribing provider or are funding and commissioning providers typically through the VCSE or prior to their abolition via Clinical Commissioning Groups (CCGs). Wider council services such as culture, parks, sport and leisure services also have a role to play in delivering social prescribing programmes. Whether that be through its infrastructure, existing or new activities.

Tips for success

1. Have you invested time in understanding the current offer and developing relationships with partners? Map out and understand the current landscape - what are the strengths and weaknesses of the existing local offer? Which organisations already have strong community connections or are delivering social prescribing? Developing and embedding meaningful community partnerships needs an investment of time, so ensure this is built into your plans.

2. How does it positively impact on your partners' local priorities? Understanding the challenges facing your partners and demonstrating how social prescribing could positively impact on their priorities will help to win over your partners. Recent research shows that 81 per cent of social prescribing service users experienced positive change in at least one outcome measure ranging from improved wellbeing, skills development and improved employment/job prospects.

3. Are your delivery partners funded and sustainable? Social prescribing is not free nor is it a cheap option, it needs to be fully resourced and sustainable. While social prescribing is a core activity of many arts, culture and leisure organisations they cannot continue to offer a high-quality offer without investment.

4. Are your procurement processes inclusive, are you taking advantage of all the opportunities available to you? Some procurement processes can deter smaller arts, cultural and sports organisations from applying to deliver social prescribing contracts because they do not have the resources. Taking measures to ensure procurement processes are reasonable for the level of funding and opportunities are open and accessible to small and voluntary organisations can help overcome this. The procurement process also offers substantial opportunities to make full use of the powers of the Social Value Act and apply the Themes, Outcomes and Measures (TOMs) of the National Toms Framework ensuring that new contracts build in additional social value to communities, such as apprenticeships, outreach and activities targeted at less active groups, or purchasing from local businesses.

5. What resources beyond funding can the council offer? For example, can you offer the use of a sports hall or other venue for social prescribing programmes to take place in?

Much of the funding that has been made for social prescribing is allocated to increasing the numbers of link workers to meet the commitment for each PCN to have a link worker. Therefore it may be necessary to think creatively about grant funding opportunities and make the connection between social prescribing for culture, sport and green spaces. This will help to encourage new and diverse audiences through the door while improving their physical and mental wellbeing and sharing the joy of local collections, parks or leisure activities.

A range of support is available through a number of national organisations.

The National Academy for Social Prescribing (NASP)

Accelerated learning in social prescribing programme

Culture Health and Wellbeing Alliance

The Culture Health and Wellbeing Alliance is a national membership organisation representing everyone who believes that creativity and cultural engagement can transform our health and wellbeing. It is free to join. It does not provide funding but it signposts to some of the organisations that provide funding for creativity and culture for health and wellbeing.

Personalised care

NHS personalised care approach means that some people with long-term conditions will be able to pay for local classes and activities (such as art classes, music clubs or a course at a local museum) as part of managing their own health and wellbeing, through their personal budgets. This gives people greater autonomy and moves away from a purely medical response to need.

National Lottery Community Fund

The National Lottery Community Fund distributes over £600 million a year to communities across the UK, raised by players of the National Lottery. Funding is available all year for projects run by voluntary and community organisations that support people and communities. Current funding has a focus on supporting the most adversely impacted by the pandemic. The Welsh funding programmes are open to public sector organisations as well as voluntary and community organisations. Funding from other National Lottery Funding bodies including Sport England and Arts Council England funding is also available.

Natural England are keen to promote the health benefits of the natural environment They are working with NASP to embed Green Social Prescribing (GSP) in social prescribing nationally. They currently have seven test and learn sites that are exploring various aspects of GSP.

Sport England's 10 year strategy " Uniting the Movement" to transform lives and communities through sport and physical activity commits to working with partners on 'connecting to health and wellbeing' and supporting 'connected communities.

Arts Council England is an administrator of funds which support social prescribing. It also supports culture-led health and wellbeing networks around the country including Arts and Health South West and the London Arts in Health Forum. Some operate on a local level, such as Leeds Art Health and Wellbeing Network, while some operate at a regional level, such as Arts Derbyshire and Arts and Health Network North East.

With their emphasis on accessibility, wellbeing and community, arts, sport, parks, leisure services and museums are all well-placed to deliver on a range of policy objectives and contribute to local recovery strategies.

Prescribing to arts and culture

The arts can have a powerful impact on people with long-term health conditions. For example, music therapy reduces agitation and need for medication in 67 per cent of people with dementia. Many councils are already delivering social prescribing programmes such as arts-on-prescription and museums-on-prescription (sometimes known as referral programmes such as arts-on-referral). This involves people experiencing psychological or physical distress being referred (or referring themselves) to engage with the arts in the community including galleries, museums and libraries.

Arts on Prescription Gloucestershire has shown a 37 per cent drop in GP consultation rates and a 27 per cent reduction in hospital admissions. This represents a saving of £216 per patient The APPG on Arts, Health and Wellbeing Inquiry cites a social return on investment of between £4 and £11 for every £1 invested in arts on prescription.

Wonder Women is an empowering project set up by Peterborough Council for Voluntary Services' Women's Forum. It included a series of creative art workshops hosted by arts organisation Metal with intuitive artist Sa'adiah Khan. The workshops were well attended, providing attendees the opportunity to meet each other and engage in conversation, while experimenting with various forms of art making. The women enjoyed exploring messy art, being playful, learning new skills and having fun with various materials. Being creative while spending time connecting to others in a safe and friendly environment proved a real boost to their mental health and wellbeing. Participants enjoyed "making art without pressure" and found it a good outlet to express themselves, in a safe environment. "These sessions have given me the opportunity to have open and safe conversations with other woman, while being creative and making."

Other examples of arts and culture social prescribing programmes include:

Dementia cafes supported by the Alzheimer's Society, these cafes have sprung up around the country - usually in museums, art spaces or libraries, offering people with dementia, and their carers, a safe, friendly place to relax and socialise and enjoy the sights on offer at the cultural venue.

Knit and natter groups bring people together socially in a group where they are occupied and conversation can flow easily.

Using archaeology to aid the recovery of military veterans: the Ministry of Defence launched Operation Nightingale in 2011 with the aim of involving wounded, injured, and sick military personnel and veterans in archaeological investigations as part of their recovery. One of the participating archaeological sites was Buster Ancient Farm in Hampshire, 26 volunteer veterans worked with archaeologists to build a traditional Bronze age round house. The build had a significant impact on the volunteers who took part.

"Working through each stage of the project has been brilliant and I still find it hard to believe how much my life has turned around because of it. Not just feeling myself again, gaining more independence and confidence, the comradery but what else the project has led onto."

- John William Bennett, Royal Navy Veteran, 2021 Archaeology Undergraduate

Prescribing to libraries

Councils have a statutory duty to provide a comprehensive service, and to encourage both children and adults to make full use of the library service and to lend books and other printed materials free of charge to people living, studying, or working in the area. They are non-judgemental spaces that everyone in the community has access to, giving them a unique role in supporting people with health conditions, connecting and supporting communities. This is exemplified through the following examples:

Reading well books on prescription(or bibliotherapy scheme) makes self-help books readily available to people to encourage greater understanding of their health condition and to learn how to better manage mental health issues such as anxiety and depression. Most libraries have a well zone where such books can be found.

Reading groups encourage people to share their thoughts about particular books or simply to sit quietly and listen to a book being read - story time for adults if you like. While groups for children encourage them to see the library as a part of their community, offering as much or as little about books as they want but providing a social space for their parents and carers who may often find themselves socially isolated at home with young children.

Prescribing to sport

The link between exercise and health is clear. Sport can also offer other benefits through social prescribing, such as a sense of enjoyment and fulfilment, and helping people connect to others and their community. Exercise on referral is one of the earliest forms of social prescribing and is usually a programme where people with long-term health conditions such as diabetes, high blood pressure, or heart disease increase their physical activity levels by regularly using local leisure centres through GP and other referrals. Like with culture and arts, sports related social prescribing needs to be imaginative and varied, tapping into activities that support people who are experiencing a range of physical and mental health conditions and wider issues like loneliness or social isolation.

East Riding of Yorkshire Council's exercise on referral scheme and the Live Well scheme continue to flourish with GPs able to refer directly via a secure e-referral system. The referral is picked up by the Central Team the day the referral is made, and they will attempt to contact the patient within 48 hours. While the exercise-on-referral is a set period of 10 weeks - Live Well can last up to a year. Over the past year about 1700 exercise on referrals have been made and 258 Adult Live Well referrals and 230 Young Live Well referrals.

Other examples include:

Singing can be its own exercise and can be beneficial to those who may, for example, have Chronic Obstructive Pulmonary Disease (COPD).

Royal Brompton & Harefield NHS Foundation treats patients with complex diseases and conditions. In 2002 rb&hArtswas set up to run innovative arts programmes for patients. In response to the Covid-19 pandemic, rb&hArts successfully piloted online Singing for Breathing sessions for 117 participants specifically aimed at people living with chronic or life-limiting respiratory conditions and were required to shield. The singing sessions provided physical exercise which supported lung function and vital space with time for a chat. The programme boosted positive mental health and created peer support networks.

Swimming is a low impact exercise that can be done at an individual's own pace and enhances mood and fitness.

Swim England ran a three year project to provide swimming for people with dementia and their carers. The project provided guidance to pools on signage and safety for people with dementia to ensure a safe space for them to enjoy the water. Health outcomes included enjoying the benefits of exercise, increased confidence in the water and an opportunity to work off some of the frustrations that both people with dementia and their carers can experience. The project was supported by DHSC funding and required the development of strong partnerships across a diverse range of public and private organisations, charitable trusts, council officers, care providers and community nurses to deliver the programme. Two pilot sites were introduced in Manchester and Durham in 2015. A year later this expanded to five including some of the London boroughs and by year three, 2017, a total of 48 pool operators were involved.

Green social prescribing

Green social prescribing links individuals to nature-based interventions and activities, such as local walking for health schemes, community gardening and food-growing projects. The pandemic highlighted the importance of being outdoors to people's mental and physical health as well as the inequality of access to private gardens and green spaces. Some innovative examples include:

Gardening can provide a 'dose of wellbeing' as demonstrated by the Eden project's social prescribing project "Nature's Way". The activity and creativity of working with plants and meeting others is helping to boost physical and mental health, reduce isolation and instil a sense of purpose.

Partnerships and referral pathways between local mental health services and social prescribing can help to reduce demand on services and provide alternatives to traditional therapies.

The 'Connecting in Nature' programme provided local Brighton and Hove residents the opportunity to connect with themselves, each other and nature as a way of supporting their mental health and well-being. While the project was promoted by the local social prescribing service, most participant referrals came through the partnership with MIND. The impact of the project was overwhelmingly positive with 100 per cent of attendees noticing a positive impact on their wellbeing from attending these sessions "Time in nature does me good, but I struggle with the motivation to do it on my own...the group gave me a much needed boost each week" Attendee, Connecting in Nature group autumn series.

Points to consider:

1. Is your council's culture and/ or sports and parks services maximising their contribution to social prescribing? How could this be developed? Can you broker introductions to health services or link workers?

2. How can you support sports, arts and cultural organisations in your area to get involved in social prescribing or expand?

3. What are the referral pathways into social prescribing activities? Could these be developed further or does it need to be streamlined? Is it a clear route and easy to navigate by service users and link workers?

4. What are the key community spaces in your area? For example leisure centres or libraries, and can these be used to signpost people to a wider range of services and social prescribing opportunities?

5. Who are the community leaders in your area? How can you work together to reach underserved groups?

Measuring impact

There is an emerging body of evidence that social prescribing can contribute to a range of local and national priorities, as outlined in the making the case section.

Measuring the impact of your social prescribing initiatives is a powerful tool for building the case for investment, as well as helping you to understanding the impacts you are having. There is not a 'one size fits all' approach to evaluating the impact of social prescribing but it is important to have consistency in the data that's collated so that effectiveness can be assessed.

If possible, try to encourage local partners to adopt the same or similar evaluation frameworks so you can compare results. You may also want to think about how you can build the capacity of smaller organisations to measure impact, for example by sharing knowledge and resources.

For a comprehensive introduction to evaluation and the various tools available, the 'Look I'm Priceless' guide is helpful. Although developed in 2016, the Public Health England framework for evaluating the impact of arts programmes on health wellbeing is still relevant as is the Creative and Credible guide (2015). The New Economics Foundation's guide for measuring impact on wellbeing is aimed specifically at voluntary and community organisations.

The NHS has developed an outcomes framework aimed at measuring three key aspects of social prescribing. All link workers employed by the NHS will be working with this outcomes framework, and it is therefore important to bear this in mind when designing local social prescribing programmes and evaluation processes. Make sure you are in regular dialogue with link workers and talk to them about how you can work together to support evaluation and share results for mutual benefit.

Supporting social prescribing in your area

We hope this guide has helped you to understand social prescribing, the role of arts and culture in its delivery, and that the case studies have inspired you to think creatively about the wealth of ways through which you can improve your residents' health and wellbeing.

There are a number of common themes found across the case studies which may be helpful to bear in mind as you go forth and develop your local social prescribing offer.

Local leadership is key to building across organisational boundaries - include PCNs, ICSs, ICBs, ICPs, voluntary and community sectors, social care and public health, GPs, link workers and local patient and carer groups.

Consider your approaches to commissioning, is it accessible to community organisations already delivering social prescribing?

Take a holistic approach - if you have not already done so, bring together organisations that include the arts, cultural and leisure sectors, to identify ways that all can contribute to improved health and wellbeing for residents

The buy-in of senior leaders and decision makers is key to developing understanding, investment and support for the frontline.

Make social prescribing a key focus for health and wellbeing boards and ICSs.

Identify strategic and commissioning opportunities to advocate for inclusion of using arts and cultural and leisure providers to improve health.

Nurture and invest in capacity especially of small organisations, support training and development initiatives for libraries, culture and leisure staff.

Take contracting approaches proportionate to the value and complexity of the services being provided to avoid excluding small community groups.

Small community groups need support, development and training rather than over complicated processes and regulation. Maintain close partnerships so that problems can be aired quickly and solutions reached.

Consider your referral pathways, are they fit for purpose, are they maximising the opportunities or do they need to be simplified?

Share and promote examples of social prescribing already in action.

Offer in-kind as well as financial support. For example, offering a venue for activity sessions or office space at a reduced rate, or providing an IT platform to advertise community events. This can particularly help to build the capacity of small voluntary and community sector organisations and may unlock greater opportunities.

It is crucial to work in partnership with local health organisations and the VCSE to understand your current local offer for social prescribing. Then, you can identify key assets and gaps, and develop a strategy to sustain and grow the offer. Finally, be creative about grant funding opportunities from organisations like Arts Council England, Sport England and the Big Lottery Fund which might align with your objectives. The focus of these may be on culture (for example) rather than health but making the connection with wellbeing can help to encourage new and diverse audiences through the door while improving physical and mental wellbeing and sharing the joy of local collections, parks or leisure activities.

Thank you to everyone who contributed to the updating of this handbook, including;

Anne Rehill, South Downs National Park

Anooshka Rawden, South Downs National Park

Bev Taylor, National Academy for Social Prescribing

Collin Harker, Par Track Limited

Deborah Neubauer, Hampshire Culture Trust -

Dr Rupert Suckling, Doncaster Council

Dr Stephanie Tierney, University of Oxford

Emma Tolley, The Eden Project

Hazel Ainsworth, Natural England

Helen Apsey, Make It York

James Bogue, Exeter City Council

Jennifer Lonsdale, East Riding of Yorkshire Council

Jo Yelland, Exeter City Council

John McMahon, Arts Council England

Kay Keane, Alvanley Family Practice

Laura Windsor-Welsh, Action Together Oldham

Mairead O'Rourke, culturerunner

Mirka Duxberry, Shropshire libraries

Nathan Winch, Greater London Authority

Nicola Gitsham, National Academy for Social Prescribing

Samantha Ramanah, Local Government Association

Sarah Yelland, Devon Community Foundation

Trevor Creighton, Buster Ancient Farm

Victoria Hume, Culture Health & Wellbeing Alliance

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What is social prescribing?

Social prescribing is a non-medical intervention to give a patient a prescription to take part in an activity, such as exercise, socialising or spending time in nature, to tackle a specific mental or physical problem. The idea is to look at a person holistically, rather than isolating their physical or mental health from the social context in which they live.

The activities on a social prescription are typically free, either provided by community or voluntary organisations or by the natural world - such as spending more time outdoors - so are being posited as providing crucial support amid cost of living pressures.

Does the NHS offer social prescribing?

Social prescribing has been embraced by NHS England, which intends to build infrastructure around the concept and embed social prescribing and other community-based approaches across the NHS. Ultimately, the NHS plans for every person in England to have access to a social prescribing service through their GP practice.

This is the biggest investment in social prescribing by any country's national health system in the world, NHS England has claimed.
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"Rather than prescription drugs, getting people active, involved in their community in activities like park run, is great for their health and a great way for them to address issues such as loneliness, obesity and mental health" said health secretary Steve Barclay, who added that the department for health and social care is committed to investing in it.

If you're keen to hear what kind of social prescriptions could help you, ask your GP if they can refer you to a social prescriber who will help you to figure out what activities might benefit your health the most.

Where have people tried social prescribing?

In the North East of England, GPs have struggled to treat the growing numbers of people experiencing loneliness and depression, but social prescribing is trying to reduce pressures on surgeries and A&E.

Health and council bosses in Gateshead have rolled out a new approach to enable doctors to prescribe days out, including to an allotment run by one local GP surgery, in an attempt to help those who are struggling.

Social prescribing link worker Julie Bray was one of the first NHS social prescribers in the country. She told the BBC it's mind-blowing "just to see the difference in some of the patients that we've worked with".
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"They build their confidence up, it reduces GP appointments, it reduces A&E appointments, and it just makes them connect with the community and be resilient", she continued.

GPs in Scotland have been writing " RSPB Nature Prescriptions " that include giving patients a calendar of ideas to help them connect with nature to boost mental health and wellbeing.

After the project was trialled in the Shetland Isles and Edinburgh, over 74 per cent of patients who received nature prescriptions said they benefited from it, and 87 per cent said they would continue to turn to nature to support their health and wellbeing.

Nature prescriptions will now be trialled in Derbyshire in England, to connect people with the Peak District National Park through prescriptions from 13 different GP practices in the area.

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Run Talk Run project across the West Midlands using an Active Practice to set up a running group for patients

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Have you ever got your heart rate up when not feeling your best? Perhaps you went for a walk or jog. No doubt you felt better for it after. That's because exercising releases those ''happy hormones''- endorphins. These lift our mood, help us de-stress, and help us sleep better. That sense of achievement in completing some often evaded physical activity gives us confidence that we can do it, which in turn lifts our self-esteem. If these outcomes were the effects of a tablet it would no doubt be highly sought after.

Telling yourself or others to get active is easily said but often there are challenges to overcome to get there. That is where Run Talk Run can help. It is a weekly mental health support running group that aims to break down barriers to exercise whilst providing a safe space for people to talk about good days, bad days and everything in between. It is a national turned global initiative that was launched in 2017 by Jess Robson, who herself at the time was experiencing depression and found running with others helped her to open up about her mental health.

Clarendon Lodge Medical Practice in Leamington Spa launched the first West Midlands Run Talk Run in July 2020. The group is led by a diverse team: Dr Hussain Al-Zubaidi - general practitioner, Dr Shahnaz Hassan - psychiatrist, Mick Hurrell - Fitness coach for the over 50s, Dominic Shepherd - social prescriber and Stephen Gallagher - practice manager.

Participants have come from all walks of life to join in the weekly adventure. Each has their own reason for attending; some have diagnosed mental health conditions, some come for their physical wellbeing and others for the social aspect. The feedback has been overwhelmingly positive, with the benefits of the group far-reaching into all components of life. Just some of the advantages participants have reported back include reduced social isolation, overcoming agoraphobia and anxiety, better sleep, the motivation to stop smoking and reach activity goals from being able to talk and run at the same time to running in races. One of the most gratifying aspects for us as leaders is to see the community come together to support each other in their goals and form connections outside the group. Several runners now meet on Saturdays to do the parkruns together, and this week two runners planned to tackle the Yorkshire peaks together on a weekend away. Some were inspired to set up other Run Talk Runs and there are now three available in the Warwickshire area on different days of the week.

There is a wealth of research on the benefits of physical activity on mental and physical health, and our project has allowed us to witness this first-hand. Our participants have shared the rewards they have reaped with others, and as such the group has grown as people invite family and friends along. Our efforts also attracted the attention of the local media and we have spoken to the local newspapers and BBC Radio about the initiative.

So if you have been convinced that social exercise has a vital role to play in wellbeing, why not try out your nearest Run Talk Run? We would also be delighted to host you at Clarendon Lodge, Leamington Spa on Tuesdays at 6.30pm.

If you have been charmed and enthused to go further, then maybe you want to consider being a run leader. Dr Al-Zubaidi, regional lead for Run Talk Run West Midlands, is your go-to for advice and support: westmidlands@runtalkrun.com.

Happy running!

If you'd like to find out more, and become part of the growing network of Active Practices, head over to the physical activity hub.

About the writers

Dr Shahnaz Hassan, Psychiatrist and Dr Hussain Al-Zubaidi, Lifestyle GP.

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Have you ever got your heart rate up when not feeling your best? Perhaps you went for a walk or jog. No doubt you felt better for it after. That's because exercising releases those ''happy hormones''- endorphins. These lift our mood, help us de-stress, and help us sleep better.

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Active Pregnancy Foundation - Postnatal CMO Guidelines

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Starting Conversations: Physical Activity Throughout the Life Course - Waiting Room Video

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The Complete Care Community Programme (CCCP) was created to explore how today’s NHS can contribute to a reduction in health inequalities in England as Integrated Care Systems (ICS) become statutory bodies and we continue to recover from the covid-19 pandemic.

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These profiles bring together data and knowledge to give a broad picture of health in the nine English regions. The reports provide a regional view of health and indicators presented in the Health Profile for England 2021.

Details

The regional health profiles provide an overview of health in each of the 9 regions. As first editions of the profiles produced to accompany the Health Profile for England 2021, they bring together data available through the OHID Fingertips platform as well as information from other publicly available sources to give a broad picture of the health of people in each region.

These interactive reports explore the prevalence, trends and inequalities in health - as well as the direct impact of COVID-19 along with some of the wider health impacts that have stemmed from the pandemic.

The regional view of health closely mirrors indicators and topics presented in the Health Profile for England 2021 and its national priorities, with data and health intelligence presented in these 7 chapters:

COVID-19

mortality and life expectancy

child health

adult health

risk factors associated with ill health

the wider determinants of health

health protection

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Health profiles for English regions: 2021

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Social Prescribing and the Power of Change | Jennifer Neff | TEDxStormontSalon

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How does the NHS in England work and how is it changing?

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ACTIVE PARTNERSHIP IMPACT REPORT_2021-2022 final

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Natural England: Green Social Prescribing

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Natural England: Green Social Prescribing

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0:00 / 0:30•Watch full video

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Subtitled Partnership working & Green Social Prescribing – GM

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Co design in Green Social Prescribing, SYB - subtitled

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Subtitled Green Social Prescribing in Nottingham

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GSP Preliminary Evaluation Findings - Protected

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Green Social Prescribing Programme Update May 2022 - Protected

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SP for young people evaluation final report for publication

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Train to deliver Love to Move

If you are passionate about making a difference and would like to train to deliver Love to Move, find out more about our courses by clicking the button below and help us reach and benefit more people.

Download our Love to Move booklet

If someone close to you is living with dementia, you will naturally want to do everything you can to help them to enjoy life as much as possible.

Our exercise booklet is available to help you try our Love to Move programme in your own home with your loved ones, containing some of the key exercises from the programme inside, as well as more information about why our programme is working.

"They've helped me to get moving. They've helped me get home again."

The Love to Move Programme has helped Jean regain her independence.

Jean wanted the chance to tell us about her story. She explained that she used to be a resident in the care home as she had lost some mobility and a lot of independence. She said it was our programme that made all the difference and helped her to get her independence back again and help her to get home again.

With your generous support, you can help more people to benefit from the Love to Move programme! Just £55 can support a group of people living with dementia to enjoy a love to Move session.

What makes our programme so effective?

Love to Move is specially designed to get older people moving and functioning better. The programme achieves this by carefully integrating the use of gymnastic foundation skills, cognitive stimulation therapy and social interaction activities. Almost every part of Love to Move is based on bilaterally asymmetrical movement patterns. This is understood to benefit older people and those with dementia and mild cognitive impairment, by enabling the left side and right side of the brain to process information independently; thus improving cognitive function, coordination and the ability to carry out activities of daily living more independently.
Above all, the programme is fun! One of our participants has said that it brings her;
"One hour of wonderfulness each week!"

"The Programme has a demonstrable benefit in the physical, emotional and cognitive aspects of older people and those older people having mild to advanced forms of dementia appear to benefit the most."

Research conducted by Age UK, June 2016

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Love to Move | British Gymnastics Foundation

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If you are passionate about making a difference and would like to train to deliver Love to Move, find out more about our courses by clicking the button below and help us reach and benefit more people.

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Office for National Statistics (ONS): Health data 2015-19

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Office for National Statistics (ONS): Health data 2015-19

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English indices of mass deprivation 2019

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English indices of mass deprivation 2019

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Statistics on relative deprivation in small areas in England. Further details are provided at the bottom of this page and in the FAQ document.

Details

These statistics update the English indices of deprivation 2015.

The English indices of deprivation measure relative deprivation in small areas in England called lower-layer super output areas. The index of multiple deprivation is the most widely used of these indices.

The statistical release and FAQ document (above) explain how the Indices of Deprivation 2019 ( IoD2019) and the Index of Multiple Deprivation ( IMD2019) can be used and expand on the headline points in the infographic. Both documents also help users navigate the various data files and guidance documents available.

The first data file contains the IMD2019 ranks and deciles and is usually sufficient for the purposes of most users.

Mapping resources and links to the IoD2019 explorer and Open Data Communities platform can be found on our IoD2019 mapping resource page.

Further detail is available in the research report, which gives detailed guidance on how to interpret the data and presents some further findings, and the technical report, which describes the methodology and quality assurance processes underpinning the indices.

We have also published supplementary outputs covering England and Wales.

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Statistics on relative deprivation in small areas in England. Further details are provided at the bottom of this page and in the FAQ document.

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The fitness and leisure sector plays a key role in providing opportunities for physical activity, achieved in part through the existence of more than 7,000 gyms, pools, fitness and leisure centres across the UK. Spanning both the public and private sectors, this infrastructure in turn facilitates a broad range of community physical activity engagement opportunities, from swimming in local lidos to exercise referral classes in community leisure centres, working out in your lunch break at the high street gym or group fitness studio to playing games in sports halls and on tennis courts.

The size and scale of the UK fitness and leisure sector, the number of people engaged and the social value generated demonstrate a shared ambition, among providers across the sector, to play a key role in improving the health of the nation. That means striving to reach even more people, too, and growth modelling by ukactive predicts that - with supportive measures from government - membership of gyms, swimming pools and leisure centres could rise to 20 per cent of the UK population by 2030.

That's an increase from 15 per cent of the population in 2019, prior to the COVID-19 pandemic, and equates to more than five million additional members.

Fill in the below form to request a copy of the full report.

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Leading the Change | Social Prescribing within the Fitness and Leisure Sector

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The fitness and leisure sector plays a key role in providing opportunities for physical activity, achieved in part through the existence of more than 7,000 gyms, pools, fitness and leisure centres across the UK.

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UK Chief Medical Officer Physical Activity Guidelines

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UK Chief Medical Officer Physical Activity Guidelines

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World Health Organisation: Guidelines on physical activity and sedentary behaviour

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World Health Organisation: Guidelines on physical activity and sedentary behaviour

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WHO guidelines on physical activity and sedentary behaviour

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The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate he…

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NICE: National Institute for Health and Care Excellence. Behaviour change: individual approaches

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NICE: National Institute for Health and Care Excellence. Behaviour change: individual approaches

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Behaviour change: individual approaches

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This guideline covers changing health-damaging behaviours among people aged 16 and over using interventions such as goals and planning, feedback and monitoring, and social support. It aims to help tackle a range of behaviours including alcohol misuse, poor eating patterns, lack of physical activity, unsafe sexual behaviour and smoking.

Recommendations

This guideline includes recommendations on:

developing local behaviour change policy and strategy

commissioning interventions

planning interventions that take account of local needs

ensuring interventions meet individual needs

delivering interventions

commissioning and providing training

monitoring and evaluating interventions

Who is it for?

Healthcare professionals

Commissioners and providers

Young people and adults, and their families and carers

Is this guideline up to date?

We checked this guideline in March 2019. We found no new evidence that affects the recommendations in this guideline.

Guideline development process

How we develop NICE guidelines

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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Overview | Behaviour change: individual approaches | Guidance | NICE

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This guideline covers changing health-damaging behaviours among people aged 16 and over using interventions such as goals and planning, feedback and monitoring

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1. Advanced Wellbeing Research Centre /

2. Projects /

3. Easier to be Active

Easier To Be Active

One in three of us in England live with a health condition and we are twice as likely to be amongst the least physically active, yet we know that being active can help to manage our conditions and increase our quality and length of life.

The #EasierToBeActive project explored the ways in which we help people with long-term health conditions lead a more active lifestyle. The project consisted of three phases:

Phase 1 – an online conversation (March-May 2020)

Phase 2 – interviews with leaders in the physical activity system (September 2020 – February 2021)

Phase 3 – a second online conversation to test and refine the findings (April – June 2021)

The collective insight from the conversations has been used to co-create new insight and recommendations for those who provide, design, commission and deliver sport, physical activity and health and care services so that we can improve the experience of being active for people with health conditions.

The documents below present the findings from the research to help inform how we can make it #EasierToBeActive for people with long-term health conditions.

Please feel free to use these documents and share them with those who would benefit from seeing them – we do ask that if they are shared, that the authors and funders are acknowledged.

The project was delivered through a partnership between Sheffield Hallam University’s Advanced Wellbeing Research Centre (AWRC), National Centre for Sport and Exercise Medicine (NCSEM) and Centre for Behavioural Science and Applied Psychology (CeBSAP), Sport England, Clever Together, and the Richmond Group of Charities.

The reports and video for this project were designed and created by Nifty Fox Creative

Publications

Research team

Dr Catherine Homer

Senior Research Fellow

Dr Anna Lowe

Programme Manager, National Centre for Sport & Exercise Medicine

Dr Martin Lamb

Research Fellow

Partners

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Easier to be Active | Sheffield Hallam University

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UK Active - Leading The Change Social Prescribing within the fitness and leisure sector

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UK Active - Leading The Change Social Prescribing within the fitness and leisure sector

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National Voices research - Rolling out social prescribing - VCSE sector experiences

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National Voices research - Rolling out social prescribing - VCSE sector experiences

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General practice physical activity questionnaire (GPPAQ) - GOV.UK (www.gov.uk)

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Screening tool used in routine general practice to provide a simple physical activity index.

Applies to England

Documents

Details

The general practice physical activity questionnaire (GPPAQ ) is a validated screening tool, used in primary care to assess the physical activity levels of adults (16 to 74 years).

It provides a simple, 4 level physical activity index (PAI). Practitioners can use this index to help them decide when to offer interventions to increase physical activity.

Published 23 April 2013

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General practice physical activity questionnaire (GPPAQ)

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Screening tool used in routine general practice to provide a simple physical activity index.

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Research - Covid-19 impacts on over 65s PA and deconditioning

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Research - Covid-19 impacts on over 65s PA and deconditioning

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An estimation of the impacts of coronavirus (COVID-19) on physical activity and falls in older adults and recommendations to mitigate these effects.

Documents

Ref: PHE publications gateway number: GOV-9256 PDF, 1.3 MB, 70 pages

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Ref: PHE publications gateway number: GOV-9256 PDF, 1.12 MB, 28 pages

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Ref: PHE publications gateway number: GOV-9256 HTML

Details

This report looks at how the wider impacts of COVID-19 have affected older people (65 years and over), with a focus upon deconditioning and falls. Estimates of these impacts on physical activity levels and rates of falls in older people are provided. The report also summarises recommendations aimed at mitigating these impacts and to improve older adult mental and physical health.

The technical appendix provides detailed information on the methods that have been used in the study.

Thank you for your feedback

Report a problem with this page

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COVID-19: wider impacts on people aged 65 and over

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