Physical Activity Referral Schemes (PARS) in the United Kingdom mainly involve healthcare professionals referring patients with a range of health conditions to leisure providers (providers of local government leisure services or charitable services). Schemes include an individualized consultation, followed by a supervised physical activity (PA) program and are usually 10-16 weeks long. In Scotland, 32 PARS have been identified across 80% of local government areas, but there is a lack of understanding about how schemes are delivered, how many people are referred, and of these, how many attend.
Systematic reviews show that PARS effectively increase PA in older participants and those referred for heart disease risk factors, but effect is unclear for other health conditions. Understanding what works well in practice is limited by the quality of routine service data, a lack of standardized definitions for uptake and adherence, and inconsistent mapping of how schemes are delivered. To address these issues, Public Health Scotland published national Physical Activity Referral Standards in February 2022 after extensive consultation with stakeholders. The ‘Standards’ aim to increase understanding of what works and improve the consistency of what is offered.
Researchers at Edinburgh Napier University (Coral Hanson, Sheona McHale) and the University of Edinburgh (Paul Kelly) have been working with scheme providers, healthcare professionals, public health specialists and policy stakeholders to understand how the Standards are being used. This has involved interviews with different potential users of the Standards to understand implementation challenges, a survey to map how schemes are delivered using the Physical Activity Referral Scheme Taxonomy, a collation of routine service data and knowledge exchange events to share learning. Awareness of the Standards is high among scheme providers (e.g. exercise professionals) and public health specialists, but lower among healthcare professionals. Providers think that the Standards are helpful and are using them in service planning, auditing service design, identifying service gaps, informing monitoring and evaluation plans, and understanding the roles and responsibilities of different partners. Barriers to implementation include uncertain funding and workforce capacity issues.
National mapping of how schemes are delivered for the 32 Scottish schemes indicate that the schemes accept a wide range of conditions, and act as a ‘catch all’ for anyone that healthcare professionals want to refer. They are mostly facility based and offer multiple PA options including gym-based activity, swimming, specialist and general fitness classes, and walking. Behavior change consultations are offered by 81% of schemes, 65% follow up those who stop attending, 47% have formal exit routes and 84% signpost to other activities after scheme completion.
The Standards include recommendations for the collection of a minimum national data set, with essential or desirable data fields for monitoring and evaluation. Twenty-six schemes (81.3%) report collecting at least some elements of the minimum data set, but implementation of data systems and monitoring is at an early stage. Most schemes are collecting demographic data (e.g. age, gender, ethnicity), but there is no standardization of data fields, making combining data from different schemes challenging. While the Standards suggest recording uptake of both initial consultation and initial activity session, schemes tend to record one or the other, reducing comparability across schemes. Attendance at activity sessions is often recorded on a different system to referral records and not easily linked together. Recording of completion (attendance at final consultations) is inconsistent and providers state that this has not previously been a priority. Providers highlight a lack of workforce capacity to implement high quality monitoring and a lack of skills to analyze data once collected.
The work in Scotland is dynamic and fast developing. Providers are engaged and want to deliver the best schemes, while recognizing the need to evolve and to collaborate. Ten scheme providers are working with researchers to improve monitoring and evaluation systems. They have agreed consistent data formats for demographic and throughput data fields to enable future cross scheme comparisons. A common data extraction form has been created and work is underway to create a national platform where the data form can be deposited and a standard report of performance automatically produced. This will make it easier for schemes to understand who is referred and who engages with what. It will also mean that schemes can compare performance at a local and national level. Finally, a national repository is being developed to serve as an interactive space for learning and good practice.
Altogether, these combined efforts represent an excellent, real-world example of developing practice-based evidence that makes Scotland one of the emerging, global leaders in the implementation and evaluation of PARS, particularly regarding the delivery and evaluation of high quality, community-based PA programs.
