The epidemics of the 21st century are environmental as well as behavioural in origin. The car, the desk job, and the screen have created an environment that leads to a range of disorders with different names given by different specialties. Hypercholesterolaemia, type 2 diabetes, the metabolic syndrome, vascular dementia, obesity, high blood pressure, and frailty are all consequences (among other things) of walking deficiency and hyper-sitting syndrome — but GPs of course need no reminding of these two problems. The working day of many GPs now results in taking only about 1500 steps, if the GP is still allowed to walk to the waiting room to invite the next patient, and fewer if they use the intercom.
Physical activity is not only preventive but also therapeutic, and the RCGP is a signatory to the excellent Academy report called Exercise: the Miracle Cure.1 The College also has a set of champions for physical activity who are making a big impression. But how can activity therapy be delivered at scale?
One approach is simply to issue an activity prescription with every drug prescription. It takes only 10 seconds to advise someone to look at the Active 10 website2 or, even better, give them a printout and write their name on it with the prescription — ‘download the Active 10 App’.
Active 10 is 10 minutes of extra brisk walking every day, and the name of the new Public Health England programme already promoted on bus stops. There is also a Walking for Health3 initiative involving the Ramblers, which should be advertised in every health centre and surgery, and ukactive (http://ukactive.com), which led local authority fitness centre developments to promote Walking Plus, namely walking plus 10 minutes of exercise for the core and upper body to improve strength, suppleness, and skill.
Ukactive is working to change the culture of primary care with regards to its understanding of and beliefs about physical activity, as well as its benefits. GPs have an appetite to encourage people to be more active but just don’t have the time to find out what is out there. They need more tools and insight into how to signpost patients towards physical activity, which becomes more important the older the patient4 and with every new condition diagnosed. For those unable to walk 10 minutes briskly outside, simply prescribe that they get up from their chair as briskly as they can, walking five steps out and back before sitting down again, and repeat 10 times. Strong thigh muscles and strength are essential to carry out the key task of getting to the toilet in time. The need for social care can be delayed or prevented by activity therapy, prescribed for every condition by double prescribing and reinforced by pharmacists by double dispensing.
For some patients activity therapy could be prescribed instead of drug therapy, either at the start of treatment or as a consequence of renewing the medication of someone who has been on antidepressants or painkillers for backache for years or decades. The BBC television programme The Doctor Who Gave Up Drugs showed how difficult it is to persuade people to try non-drug treatments, but people who aren’t making any progress on drugs can be helped to reflect and review. The social prescribing initiative that is gathering momentum will help change the culture. For many patients, activity therapy should be prescribed for 3 months before drug therapy is introduced. Diabetes UK emphasises that ‘if you have Type 2, you may initially be able to manage your condition with diet and exercise’.5 Many people will still need drug therapy, but starting with the pills sends the wrong message.
But let’s not forget the sedentary GP. Every surgery should have a staff activity programme that enables every member of staff to download the Active 10 App and take 10 minutes of brisk walking, and brisk means brisk — a walk in the middle of the day with 5 minutes of stretching and strengthening before and afterwards.
- © British Journal of General Practice 2017