Sample characteristics
Of 294 patients in the total sample, 190 (64.6%) were female, 261 (88.8%) were of White ethnicity, and 116 (39.5%) were in the fourth and fifth most deprived population quintiles (Table 1). Thirteen (56.5%) GPs were female, nine (39.1%) were aged ≥51 years, all were White, and 13 (56.5%) had been qualified as GPs for ≥16 years (Table 2). One, two, or three problems were discussed in 155 (52.7%), 85 (28.9%), and 43 (14.6%) consultations, respectively, while 10 (3.4%) consultations covered ≥4 problems; data for one patient not recorded. The mean consultation duration was 11 mins 56 secs (range 1 min 19 secs–37 mins 54 secs).
Table 1. Sample characteristics of all patients (n = 294), and patients in consultations relevant to guideline-recommended physical activity advice (n = 175)
Table 2. Sample characteristics of GPs (n = 23)
Physical activity discussions
Physical activity advice was, or would have been, relevant to management according to clinical guidance in 175/294 (59.5%) consultations (Figure 1). Table 1 summarises the patient characteristics of this sub-group. Of these 175 consultations, 64 (36.6%) included physical activity discussions as part of the management plan (Figure 1), with a mean duration of 12 mins 42 secs (range 3 mins 26 secs–34 mins 18 secs). The depth of physical activity discussions was judged as ‘meaningful’ in 22/175 (12.6%) consultations and ‘superficial’ in 42/175 (24.0%) consultations.
Figure 1. Transcript inclusion flowchart.
The authors identified 111/175 (63.4%) consultations as representing ‘missed opportunities’ to discuss physical activity according to related clinical guidance (Figure 1), with a mean consultation duration of 13 mins 19 secs (range 1 min 19 secs–37 mins 54 secs). Examples of clinical presentations in which physical activity advice was not directly relevant included simple urinary tract infections and skin problems.
Influence of the presenting problem
When it was given, physical activity advice was provided most frequently for musculoskeletal problems (40 consultations, 15 of which were considered meaningful), mental health problems (17 consultations, seven of which were considered meaningful), and cardiometabolic problems (11 consultations, three of which were considered meaningful). Cardiometabolic problems included conditions such as hypertension, obesity, and type 2 diabetes (data not shown). Mentions of physical activity included the following:
‘I think generally it’s thought, it’s weight bearing as well during exercise is better. And swimming is good in terms of you getting your heart rate up, and so on. I’m not saying you have to go running or anything like that, but just a brisk walk, anything like that … because it just loads the joints a little bit. Do you see what I mean?’
(GP, male)
GP:‘Are you exercising?’
Patient:‘No, I don’t really have enough time.’
GP:‘Yes, it’s a struggle, isn’t it? Try and make time for it because it will improve your anxiety as well, ideally at least half an hour of brisk walking every day will dramatically improve things.’
Patient:‘I do that, I walk everywhere.’
GP:‘Good. Officially studies suggest three hours a week of cardiovascular exercise, where it’s actually making you sweat. So if you can achieve that, over the months you will just start to notice slowly a benefit from it.’ (GP: female; patient: female, aged 18–30 years)
Musculoskeletal problems sometimes included signposting or referral to other professionals, such as physiotherapists, for specific exercises as part of a management strategy:
‘What we could do to help that would be to get you to see either the physio or the chiropractor — we can talk about the differences between those — who would help you to strengthen up your back.’
(GP, female)
There were some examples of GPs advising on moderating activity, because to a limitation, or avoiding activity all together:
‘I would not swim until you’ve seen the musculoskeletal people because swimming for the shoulders can be … if you got a tear.’
(GP, female)
For cardiometabolic problems, physical activity advice was sometimes given as part of management for multiple modifiable risk factors:
‘A lot of people do have high blood pressure that need[s] medication for life, but if there’s a recognisable thing that we think is causing it and you’re at that borderline level, then often making lifestyle changes, looking at your exercise, looking at your diet, looking at your salt intake, looking at your alcohol intake, all of these things can make a huge difference.’
(GP, male)
Furthermore, there were examples of missed cues when a patient offered opportunities for the GP to provide support:
GP:‘Because the thing is that I suspect that what that is doing is just reducing the very borderline hypertension, which is obviously having an impact on your renal function.’
Patient:‘This is it, I’m not really keen on taking another drug at all, but it’s just that this is ridiculous.’ (GP: female; patient: female, aged 66–80 years)
In consultations in which physical activity was relevant but not discussed, the focus of the consultation was often another overriding presenting problem that was not relevant to physical activity — for example, a consultation for cellulitis that also included a discussion about hypertension. Physical activity advice also tended to be omitted when clinical management focused on other interventions, such as encouraging a patient to engage in counselling for a mental health presentation or medication titration for hypertension.
Multiple problems and medical complexity
Patients often presented with multiple problems — such as musculoskeletal, mental health, and cardiometabolic problems — at least one of which could justify physical activity advice. The presentation of multiple clinical problems did not seem to influence whether, or how, physical activity was discussed, with the average number of problems being approximately two in all scenarios. During one consultation, the GP gave a limited response to cues to discuss guideline-recommended physical activity in a patient with a background of rheumatoid arthritis, depression, lipid disorder, and elevated blood pressure:
Patient:‘When I’m feeling well I don’t sit around, I am active. I go up in the garden … I try not to set my goals too high. So I do exercise, not so much walking, but I try to bend up and down.’
GP:‘Yes. I think that is all good. Again, I’m not sure how much that alone will lower the blood pressure by itself … we need to get your blood test done, we can check your cholesterol … given how the blood pressure’s been … might be a longer-term issue.’
Patient:‘I was going to try and do a little bit of swimming, but I must admit I haven’t really stuck to that. I know I should probably do a bit more exercise … And I would like to lose some weight, but I don’t know how you’d do that when — my appetite is huge sometimes … that is one of the drawbacks with the prednisolone.’
GP:‘Yes, yes. I don’t think there’s an easy way around that … Anything that you can make, a small sustainable change.’ (GP: male; patient: male, aged 51–65 years)
