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NICE calls for greater emphasis on encouraging exercise in QOF

GPs should be encouraged through the QOF to routinely encourage greater levels of physical activity in their patients - including gardening or vacuuming - in order to prevent a wider range of diseases, recommends NICE.

The updated public health guidance, which calls for GPs to question every patient about their exercise habits, says that including such screening and advice in QOF measures would ‘raise the profile of physical activity among primary care practitioners’.

The updated recommendations were first outlined last November and are seen as part of the Government’s idea to ‘make every contact count’, now enshrined in the NHS Mandate.

However, leading GPs have raised concerns about the feasibility of screening patients opportunistically regarding exercise and the GPC vehemently opposed the introduction this year of two new QOF indicators requiring GPs to screen patients with hypertension for physical activity levels, because of the additional time and complexity this adds to consultations.

Despite such concerns, the final NICE guidance issued today advises GPs to opportunistically screen all patients, using a validated risk tool such as the general practice physical activity questionnaire (GPPAQ) to identify any with lower than recommended physical activity levels and then offer them brief advice on taking more exercise, with follow-up visits to check on their progress.

The guidance states that ‘physical activity could be more widely linked to the prevention or management of clinical conditions through mechanisms such as the quality and outcomes framework’.

This would ‘raise the profile of physical activity among primary care practitioners’ and ‘may also encourage GPs to assess people’s physical activity levels and give them brief advice’, it says.

However, Dr Richard Vautrey, GPC negotiator and a GP in Leeds, said the proposals were ‘unrealistic’. He said: ‘I think GPs will continue to use their clinical judgement as to when to assess patients for physical activity, as they already do day in day out. It’s unrealistic for them to screen every patient.’

‘We have already seen problems with the GPPAQ adding significantly to GPs’ workload as a result of the new QOF hypertension indicators. It is not simply a case of putting these things into QOF as that does not mean there will be adequate funding for the work involved,’ he added.

The Government currently recommends adults take at least 150 minutes of moderate-intensity physical activity each week, broken down into bouts of at least 10 minutes at a time. Moderate exercise includes every-day activities such as vacuum cleaning, brisk walking and pushing a lawn mower, as well as recreational ones such as water aerobics, doubles tennis and volleyball or basketball.

Although evidence from the UK on the impact of brief advice is limited, the guidelines advisory committee reviewed relevant studies from elsewhere as well and concluded that ‘brief advice has a modest, but consistent, effect on physical activity levels’.

According to the recommendations, GPs should tailor brief advice according to the patient’s individual motivations and circumstances and any medical condition or disability. They should also provide information about the activities available locally for people to take part in, whatever their ability levels and needs.

Dr Matt Kearney, a member of the NICE Public Health Interventions Advisory Committee, which developed the guidance, and a GP in Runcorn,said: ‘As a practising GP, I see first-hand the effects of physical inactivity, and the lasting and serious damage it can have on people’s health. This guidance offers practical advice to people working in busy clinics and will help us to give straightforward advice to people who need to improve their levels of physical activity.’

Lifestyle advice enthusiast Professor Mike Kirby, a professor of medicine at the University of Hertfordshire and a GP in Radlett, Hertfordshire, told Pulse: ‘I’m quite keen on the idea of making every contact count and exercise being raised all the time. It’s about doing this in the same way as getting people to stop smoking – it only takes a few minutes but the effect builds over time. We should be treating alcohol, exercise and smoking in the same way.’

However, Professor Kirby acknowledged that many GPs will not feel able to do the extra work. He said: ‘I think they’re being asked to do so much at the moment. You’ve got a ten-minute consultation and the patients come with a problem, not to talk about exercise.

‘I think GPs feel, “I’m meant to do this, but it leaves very little time to deal with problems people are coming with”. It’s a distraction and I don’t think they’re really convinced about the evidence base that this works.’

He added: ‘I think the guidance will help but it’s not mandatory. Unless this is funded I think people will feel it’s just another thing to do. They can’t keep on taking on extra tasks as well as sorting out the patients who are ill. A lot of GPs really feel under siege at the moment.’

NICE - Physical activity: brief advice for adults in primary care (PH44)

Readers' comments (11)

  • As a gp I see first hand the pointlessness of targets and Qof and tick boxing ,
    I think everyone agrees exercise is good, so why no public health campaign about it if it that's good.
    The smoking ban had nothing to do with Qof but did far more to encourage behaviour change in a short period of time

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  • THe nanny state is alive and kicking!

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  • Isn't it odd how, over time, QOF has come to include all kinds of absurdities like the now removed PHQ9 and the newly introduced GPPAQ.

    This mission creep is yet another reason why taking back OOH would be a ridiculous idea.

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  • David Bush

    I think we are now reaching a watershed. The inclusion of all sorts of niceties in QOF has ruined what was, at first, a powerful tool for chronic disease management. It is time we completely reassessed the purpose of QOF. Keep in the undisputed necessities (BP in CHD, retinopathy in diabetes etc) but sling out all the time wasting, politically motivated indicators. Use the saved time to see, listen to, and help patients who present with problems.
    There is a place for reactive medicine as well as proactive disease prevention, and we must start seeing time as our scarcest resource and start to manage it appropriately.

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  • Let's include another tick box for wiping their arse for them!!

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  • Must go home and urge more vacuum cleaning - will go down well I think!

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  • wonder who is going to get the 'more vacuuming advice.........wonder where they will advise the hose should go...

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  • What's next?

    VCON1 percentage of patients who are explained how good conservative part is
    VCON2 percentage of patients who are encouraged to vote for Conservative party
    VCON3 percentage of patients who will vote for Conservative party

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  • There is actually very little evidence that exercise promotes health and longevity. Not eating too much, keeping warm, having a calm disposition, and not working too hard, are much more important.

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  • It just beggars belief.
    In midwifery my wife booking patients is supposed to sign that she has given patients tree loads of leaflets they will never read - but more incredibly the leaflets are not available - so now she has to sign that she has not given them and the reason why [cut backs and cost of printing precludes the Trust supplying them!]

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