‘Cycling On Prescription’: a gear change or a wrong turn?

ON YOUR BIKE

My last research activity was a 3-year study, Cycle Boom,² on cycling in the older population. I interviewed 50–80 year-olds about their cycling histories to find the contexts in which there was continuation, rediscovery, disengagement, or absence of cycling through the life-course. This revealed the physical, social, and cultural factors that enable and empower older adults to achieve longevity in, or rediscovery of, cycling. Reasons for diminished motivation or confidence for cycling were multifactorial. Changes in cycling behaviours were often provoked by life events: starting a career; moving job or home; having children; change in health status; and/ or becoming a carer.

When I discuss physical activity with patients, I recall those personal accounts of cycling. My conversations with patients explore and validate their existing physical activity, whether that is walking, gardening, housework, or hobbies. I emphasise the benefits of activity for mood, sleep, stress and anxiety, and conditioning, as well as the better-known effects on weight management and cardiovascular risk.

I viewed physical activity as a ‘best-buy’ for health promotion, one that simply needed pushing up the clinical agenda. But in time-pressed consultations it is challenging to have discussions that empower the patient, given their individual circumstances and motivations. Beyond the surgery walls, conditions for cycling can make it tough to start, or restart, cycling. Clinicians will be wary of laying unrealistic expectations on patients, risking undermining the relationship with the patient.

If ‘cycling on prescription’ hopes to achieve a healthier population, then I fear the Prime Minister is in the wrong gear at the bottom of a steep hill. The NHS could make a bigger improvement on conditions for cycling and walking through its workforce, estate, supply chains, and management activity.

The NHS replenishes its workforce continually, every year training significant numbers of individuals who go on to spend long careers in service. Research indicates that changes in employment, and transitions from education to employment are change points for travel habits.³ These changed behaviours can influence and fix wider household travel resources, attitudes, and behaviours.

In my cohort of 200 student nurses I was one of only three who commuted by bicycle. There was no promotion of cycling as a healthy and affordable commuting choice, and there are no tax-efficient cycle purchase schemes available to students. The acute trust where I trained offered a secure cycling compound and changing rooms that were regularly used to capacity. Now in general practice, my bike stands alone in a makeshift store under the staircase and I’ve learnt that provision for cycling at smaller NHS premises is patchy at best. The NHS has a footprint that extends into most communities. This gives an opportunity to increase the visibility of cycling through the provision of cycle infrastructure and an uplift of staff who cycle.

Modern health care is a transport-intensive business that generates vast numbers of logistics related trips. My own medium-sized practice sees a steady flow of trips through the day. Scale this up and it is apparent that the NHS has great potential to influence the environment to promote cycling. A good model is the recent transformation in health logistics in Copenhagen,⁴ where a thorough review⁵ using logistics-planning principles led to measures including the use of a fleet of e-cargo bikes. These proved more efficient and reliable in city traffic and the service saw staff absences fall. ‘Cycling on prescription’ is a promising tool for health promotion suited to delivery through primary care, but clinicians will be understandably cautious in advocating cycling to the uninitiated or lapsed cyclist, particularly where local conditions remain challenging.

The NHS has an unparalleled opportunity to influence the conditions and experiences of cycling in the UK via a focused effort to promote cycling to its staff and logistic networks. As well as enhanced NHS efficiency and staff wellbeing, such efforts would enable and empower the wider population to cycle.