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Diane Crone at the University of Gloucestershire has been involved for over a decade in the design, delivery, evaluation and research both of exercise referral schemes and the use of physical activity for people with mental health problems. In this network page, she welcomes the Mental Health Foundation's new Up and Running? campaign that aims to promote exercise as an alternative to medication for treatment for mild and moderate mental health problems, and challenges the leisure industry to open its doors to people with mental health problems.

The link between physical activity and mental health has been documented in the literature for many years. However, turning evidence into practice has always been challenging, and although the use of physical activity for mental health in both mental health services and the community is growing, it is still a relatively new area. A campaign launched earlier this year by the Mental Health Foundation aims to address this, and highlights the role of exercise in combating depression.

Launched in March 2005, the Up and Running? campaign aims to raise awareness of the effectiveness of exercise in preventing and treating mild and moderate mental health problems, including depression and anxiety. It strongly promotes the use of exercise referral schemes as the medium to achieve this. Up and Running? campaign materials can be found on the Mental Health foundation website at www.mentalhealth.org.uk.

Exercise referral schemes are by far the most common physical activity programme developed over the last decade, and now exist in most towns and cities. Schemes involve a health professional - usually a GP - referring a patient to a leisure professional for a programme of supervised exercise, which is usually offered at a reduced price. Patients referred to these schemes commonly include those at risk of coronary heart disease, or people already displaying risk factors such as hypertension, diabetes and obesity. But there is an increasing trend for these schemes to encourage the involvement of people with mental health problems: for example, the Healthy Options programme in the Mendip district of Somerset does just this.

Despite the proliferation of exercise referral schemes, there still remains conflicting evidence about their efficacy in health improvement (Gidlow et al, 2005). The publication by the Department of Health in 2001 of the National Quality Assurance Framework (NQAF) for exercise referral schemes (Department of Health, 2001) was a significant step forward for exercise referral schemes.

This document acknowledges and recognises the important role that physical activity professionals, exercise scientists and health care professionals play in multi-agency partnership projects to promote physical activity to medically symptomatic individuals in health care. In the introduction, the secretary of state for health highlights the shared responsibility of and need for partnership working between health services, leisure providers and the individual:

'The health service has a key role to play in giving people not only advice, but also the support they need in making changes to improve their health. Referral schemes can form an important option. By working in partnership with appropriately qualified fitness and leisure providers, primary care teams can offer people real opportunities to take part in safe and effective exercise.' (Department of Health, 2001)

The NQAF provides guidelines for exercise referral schemes, setting improved standards for schemes already in existence and providing guidance for those under development. The document is significant because it places exercise referral schemes firmly on the public health policy agenda. All schemes should be following these guidelines.

By raising awareness of exercise referral schemes, the Mental Health Foundation's Up and Running? campaign is another significant step forward for referral schemes. However, people with mental health problems and their health care professionals should be mindful that leisure professionals delivering these programmes may have limited knowledge of mental health problems, and of the evidence base regarding physical activity and mental health. There are currently only two training courses in the leisure industry that focus specifically on mental health (see box).

Using exercise referral schemes for the promotion of mental health is logical, given their proliferation within the community. However, there are some issues that should be considered when service users and health professionals link up with local leisure providers to access these schemes.

* Exercise referral schemes are usually managed through multi-agency groups, including leisure providers, local government and primary care professionals. These groups often have an established remit to deliver a scheme, with clearly defined referral criteria. New partners from mental health services need to be aware that these may need to be changed in order to accommodate people with mental health problems.

* Funding for schemes is often negligible, and patients typically pay for their own physical activity programme, usually but not always at a reduced fee. Most referrals to such schemes are people with physical health problems such as diabetes, hypertension and obesity.

* Leisure providers will need to develop an understanding of mental health problems and the symptoms that may be experienced by participants. Staff who deliver programmes need to have undertaken training in these issues, and develop some understanding of the evidence base regarding exercise and mental health (see Grant (2000) for a good summary).

* Participants with mental health problems are more likely to drop out. Exercise professionals should be prepared for this, and explain to the client that this is not abnormal. Schemes need to be flexible to allow the client to restart after dropping out.

* People with mental health problems may need more social support than is commonly available on most exercise referral schemes. Some schemes - like the Healthy Options programme in Mendip in Somerset - have addressed this and modified their exercise referral scheme to accommodate the needs of people with mental health problems.

Exercise referral schemes are an appropriate medium for people with mental health problems, but as with any area of practice, One model does not fit all'. Remember that referral schemes were initially set up to address physical health inequalities. When using or setting up such schemes, it is important that they can cater for the very varied needs of people with mental health problems.

The NQAF document recommends that exercise referral schemes should incorporate a client-centred approach. Only if this is intrinsic to the design and delivery of schemes will they be effective in achieving longer terms changes in physical activity that can be beneficial for participants' mental and physical health.

Further information

Up and Running? campaign materials and document can be accessed on the Mental Health foundation website at www.mentalhealth.org.uk or t 020 7803 1100.

The Network Page is your chance to share information or make contact with others. If you are involved in a network, innovative project or have a new publication, why not tell other A Life in the Day readers about it? Contact: Adam Pozner, TriNova Research, Development and Training, 82C Oakfield Road, London N4 4LB 1020 8347 5446 e adampozner@trinova.freeserve.co.uk

References

Gidlow C, Johnston L, Crone D et al (in press) Attendance of exercise referral schemes in the UK: a systematic review. Health Education Journal.

Grant T (ed) (2000) Physical activity and mental health national consensus statements and guidelines for practitioners. London: Health Education Authority.

Department of Health (2001) Exercise referral schemes: national quality assurance framework. London: Department of Health, ww w.dh .gov.uk/Publications

Copyright Pavilion Publishing (Brighton) Ltd. Aug 2005
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