How Effective Are Exercise Referral Schemes?

Introduction

Exercise referral schemes were introduced in the mid-1990s to help people living with chronic medical conditions improve their health through physical activity and lifestyle modifications.

People are typically referred to exercise referral schemes by healthcare professionals if they have one or more long-term conditions that could be better managed or improved by specialist exercise programming.

Exercise referral schemes are now common. In fact, a 2024 report found there were 625 schemes across the UK, with potentially hundreds more not included in that report [1].

While it is clear referral schemes have grown in numbers, there is very little literature on their long-term success and whether they offer any meaningful health outcomes for those living with long-term conditions.

So, based on the latest evidence and data, this article explores the effectiveness of exercise referral schemes in the UK.

How is the Success of Exercise Referral Schemes Measured?

Most referral schemes have inclusion criteria that define the specific conditions and thresholds at which they will work with clients. For example, clients who are overweight and/or have hypertension must present with a certain BMI or blood pressure reading to be accepted onto the scheme. When these health markers respond to the intervention, the programme can broadly be considered as successful.

Typically, exercise referral clients have a final assessment in which a medical professional collects data to demonstrate whether the scheme has been effective or not. Objective health data will vary from one scheme to the next, although schemes might measure:

• Cardiovascular health – Reduced blood pressure and cholesterol profiles.
• Metabolic indicators – Improved glucose controls or fat loss.
• Body composition – Changes in BMI or body composition.
• Musculoskeletal health – Improved muscular strength or flexibility.

Unfortunately, many exercise referral schemes “fail to define specific goals and targets for their clients” according to one study [1]. That makes it difficult to determine whether the intervention has been effective or not. Instead, schemes focus on engagement and participation rates, which while useful, do not determine the impact of the scheme.

It is also worth noting that there is no standardised exercise referral model. Each scheme varies in design, delivery, focus and priority, making it difficult to compare the effects of one to another. These challenges make it difficult to say with any certainty whether exercise referral schemes are effective in the long-term.

The Limitations of Exercise Referral Schemes

While exercise referral schemes provide tailored support for patients living with long-term conditions to better manage their health, research supporting their effectiveness is not entirely positive. There a number of reasons why, including, but not limited to:

1. Lack of behaviour change

It is no secret that cultivating motivation and re-programming habitual behaviour around physical activity takes time – often far more than the 12-weeks (sometimes less) typically offered by exercise referral schemes.

Many critics believe that short-term interventions like exercise referral schemes fail to address the root causes of inactivity or unhealthy diets. For example, many patients lack the self-efficacy and motivation to change their activity levels or eating habits. Some of the most successful exercise referral programmes are those that include techniques like motivational interviewing or health and wellbeing coaching to support the client longer term.

One study focusing on the effectiveness of exercise referral schemes found that out of 17 sedentary people referred to a scheme, just one remained moderately active after exiting the scheme [2]. This demonstrates the importance of supporting clients with the underlying issues that prevent them from changing healthy behaviours.

2. Poorly defined goals and objectives

A 2024 report revealed that over one third of exercise referral schemes did not explicitly state their objectives [1]. Even more concerning, another study found that even when the exercise referral scheme did have a clear goal, they were not measurable nor time-bound [3].

The lack of clarity and urgency is highly likely to filter down and affect patients. It may also be a contributing factor behind why the results of many exercise referral schemes are so underwhelming. When patients enter a scheme without an understanding of what they are working towards, it becomes much harder for them to stay motivated, especially those who were sedentary or experience higher levels of pain.

It is also worth considering that when clients do not have clearly defined targets, they are much more likely to struggle to understand the value of performing the underlying activities that support that goal.

3. Poor attendance and completion rates

Multiple studies have reported that a large proportion of patients drop out of exercise referral schemes before their planned end/exit date. On average, 37.8% of participants exit the scheme before the six-week assessment point, while around 50.3% exit before the 12-week assessment [4]. There are likely to be a wide range of individual factors responsible for these dropout rates, but some of the more common issues include:

• Access issues – Transport, cost, and scheduling can limit participation.
• Slow results – Lack of progress can lead to discouragement and dropout.
• Low motivation – Patients might lack the support to stick with exercise.
• Health barriers – Chronic conditions may make exercise intimidating.
• Limited support – Inconsistent follow-up may reduce commitment.
• Psychological barriers – Fear of judgment can hinder involvement.

In another review of exercise referral schemes, NICE reported that “while exercise referral schemes led to a small but significant effect in the short term (6–12 weeks), these results did not persist into the medium (6 months) or longer term (1 year).”

They also went on to explain that “while many schemes have a positive effect on physical activity levels, the additional benefits to health were only small compared to other interventions, like giving people brief advice about physical activity [10].” It does appear that many referral schemes seem more focused on tracking participation and attendance rates instead of evaluating the success of the programme with more objective health and wellbeing data.

The Benefits of Exercise Referral Schemes

While there are a number of questions over the long-term viability of exercise referral schemes, overall, there remains a good body of evidence to support their use when the appropriate policy guidance is followed.

1. Removing barriers to physical activity

Exercise referral schemes are effective at removing barriers to exercise, especially for those with a lower socioeconomic status who may not be able to fund or prioritise the cost of a gym membership, let alone paying for a fitness instructor or personal trainer.

People living with long-term health conditions often feel apprehensive about exercising independently or worry about worsening their condition. Others simply do not have a strong enough understanding of how to exercise safely or where to start. Many people also report that they simply feel too self-conscious about exercising in a public space. This is where exercise referral schemes prove most effective because they allow patients to meet likeminded people with similar challenges, experiences, and history.

A 2016 NICE publication reported that people on exercise referral schemes were 12% more likely to achieve 90 -150 minutes of moderate exercise per week compared to those not involved in a scheme [6]. The same study also found that, on average, referral schemes increased the number of minutes per week of physical exercise by over 55 minutes [6].

2. Specialist and tailored support

Exercise referral programmes are characterised by supervised exercise that is tailored to the specific needs and preferences of the client. Data shows us that this one-to-one support plays an important role in attracting clients and keeping them committed to regular exercise – at least while the supervision is in place.

As previously discussed, it is common for people living with long-term health conditions to feel anxious about exercising because they are wary of exacerbating their symptoms. This is precisely why having a structured and tailored plan with supervised support from a specialist exercise referral instructor makes such a difference to long-term exercise adherence. In many cases, it’s peace of mind that patients have never had before.

Qualitative research reported that instructors provide a “positive impression of exercise referral schemes to reduce any fears” to help break down any pre-existing barriers or objections to exercise. The same study also found that exercise referral instructors were “more successful in engaging older adults in exercise if they were part of a specific referral system with clearly defined goals and support [7].”

3. Improved health markers and data

There is evidence to suggest that exercise referral schemes have a meaningful impact on key health indicators and quality of life markers.

For example, referred patients living with cardiovascular disorders showed reductions in both blood pressure and Body Mass Index (BMI). Self-reported activity levels also increased according to one study [8]. Another study found that exercise referral schemes improved patients’ cardiorespiratory endurance in 20 out of the 29 (68%) participants [9].

Ideally, participants should be able to demonstrate tangible improvements with key health markers, including, but not limited to, blood pressure, body weight, functional movements and capacity, blood glucose control, respiratory function, or any other objective data to support their physiological progress. Even broader and more lifestyle-related outcomes can be useful, including self-reported caloric intake, smoking cessation, and/or alcohol consumption.

How to Improve Exercise Referral Engagement and Adherence?

Long-term adherence to exercise referral schemes is a challenge facing commissioners and operators alike. Most patient engagement levels decline over time, especially beyond the initial programme duration where exercise is typically supervised.

We already know that 37.8% of participants exit before the six-week assessment and 50.3% exit before the 12-week assessment [4]. And we also know that the physical and mental improvements clients experience in 12 weeks schemes, did not persist in the 6-12 months that followed.

It is clear that there is a need for a more comprehensive approach to behaviour change, in which exercise, physical activity and healthy eating are explored in a different way. One such initiative is health and wellbeing coaching services.

A health and wellbeing coach would hold a conversation about changing their habits in a non-judgemental tone, while respecting and honouring the client’s right to autonomy.
Instead of trying to get the client to agree to change, the coach will explore the client’s resistance to change without expectation that they will. This generally creates a safe space for change to progress more organically as and when the client feels ready.

We know that person-centred behaviour change conversations have better long-term effects on adherence, so incorporating these interventions into exercise referral services could make a tangible difference to the long-term success of such schemes.

Conclusion

Exercise referral schemes can be broadly effective in helping patients living with long-term conditions to improve their health and wellbeing on some level. At the very least, the structure and support of programmes often encourage physical activity among people who would not ordinarily exercise.

There is now evidence to suggest that schemes with clearly defined goals and well-qualified instructors can provide the greatest support to clients that need to improve key health markers and their long-term attitude towards physical activity. Schemes must, however, take the time to define their objectives from the outset, and collect the relevant data at key client touchpoints to determine whether they have been effective.

Sadly, it does however appear that once clients exit exercise referral schemes and are no longer accountable to their instructor or scheme coordinator, there is a marked fall-off in participation and compliance.

References

[1] Jane B, Downey J. Exercise referral schemes in the UK: mapping provision and aims. J Public Health (Oxf). 2024 Aug 25;46(3): e477-e482.

[2] Williams, N. H., Hendry, M., France, B., Lewis, R., & Wilkinson, C. (2007). Effectiveness of exercise-referral schemes to promote physical activity in adults: Systematic review. British Journal of General Practice, 57 (545), 979–986.

[3] Murphy, S. M., Raisanen, L., Moore, G., Edwards, R., Linck, P., Hounsome, N., Williams, N., Din, N., & Moore, L. (2010). The evaluation of the National Exercise Referral Scheme in Wales (Social research; No. 07/2010). Welsh Government.

[4] Kelly, M. C., Rae, G., Walker, D., Partington, S., Dodd-Reynolds, C., & Caplin, N. (2016). Retrospective cohort study of the South Tyneside Exercise Referral Scheme 2009–14: Predictors of dropout and barriers to adherence. Journal of Public Health, 39(4), e257–e264.

[5] National Centre for Sport and Exercise Medicine – East Midlands. (2010). Section 3: Exercise referral research. In A toolkit for the design, implementation & evaluation of exercise referral schemes (pp. 8–28).

[6] Campbell, F., Holmes, M., Everson-Hock, E., et al. (2015, October 14). Exercise referral schemes increase physical activity for some. National Institute for Health and Care Research.

[7] Shore, C. B., Galloway, S. D. R., Gorely, T., Hunter, A. M., & Hubbard, G. (2021). Exercise referral instructors’ perspectives on supporting and motivating participants to uptake, attend and adhere to exercise prescription: A qualitative study. International Journal of Environmental Research and Public Health, 19 (1), 203.

[8] Rowley, N., Mann, S., Steele, J., Horton, E., & Jiménez, A. (2018). The effects of exercise referral schemes in the United Kingdom in those with cardiovascular, mental health, and musculoskeletal disorders: A preliminary systematic review. BMC Public Health, 18 (1), 949.

[9] Inkpen, S. J. L., Liu, H., Rayner, S., Shields, E., Godin, J., & O’Brien, M. W. (2024). Exercise referral schemes increase patients’ cardiorespiratory endurance: A systematic review and meta-analysis. Preventive Medicine Reports, 45, 102844.

[10] National Institute for Health and Care Excellence. (2014) Exercise referral schemes: guidelines. National Institute for Health and Care Excellence.