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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)


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