The Public Health Interventions Advisory Committee (PHIAC) took account of a number of factors and issues when developing the recommendations, as follows. Please note: this section does not contain recommendations. (See Recommendations.)
3.1 The recommendations have been made within the context of other national and local strategies and interventions to increase or maintain physical activity levels. Further, the availability of local opportunities to be active will influence whether brief advice leads to an increase or maintenance in people's physical activity.
3.2 PHIAC noted changes to the NHS and public health systems which came into force from April 2013, when local authorities took over responsibility for many public health interventions and services. Specifically, it noted that these changes may result in some uncertainty about who will coordinate and commission work in the immediate future.
3.3 PHIAC acknowledged and considered the 'making every contact count' (MECC) principle, as outlined at the 2012 NHS Future Forum, in developing this guidance. MECC suggests that by ensuring 'primary care professionals are appropriately trained and confident to make the most of opportunities with which to help people stay healthy', this will reduce system-wide costs to the NHS.
3.4 PHIAC considered that physical activity could be more widely linked to the prevention or management of clinical conditions, through mechanisms such as the quality and outcomes framework (QOF). This approach would, it felt, be one way to raise the profile of physical activity among primary care practitioners. In turn, this may also encourage GPs to assess people's physical activity levels and give them brief advice.
3.5 PHIAC acknowledged that there is a need for all healthcare practitioners and policy makers to view the encouragement of physical activity as a normal, routine part of their practice.
3.6 PHIAC acknowledged that there are a number of competing demands on primary care practitioners' time, both generally and during patient appointments. The recommendations allow for practitioners to deliver very brief informal advice repeatedly, if this fits better with the time available.
3.7 PHIAC noted evidence that suggests brief advice could be delivered more quickly if the practitioner is knowledgeable about the benefits of (and opportunities for) physical activity. Evidence also points to the value of receiving training in delivering brief advice.
3.8 PHIAC acknowledged that some primary care practitioners do not talk to people about physical activity. This may be due to a number of reasons, for example, a lack of knowledge of the benefits or the types of activity they should be recommending. PHIAC acknowledged that the attitudes of both primary care practitioners and patients are important in determining whether a brief intervention is carried out and whether it has an effect.
3.9 PHIAC acknowledged that there may be fewer opportunities to be physically active in areas of high deprivation. This may be because of people's perceptions of personal safety locally or the location and accessibility of facilities such as parks and leisure centres. It could also be due to the lack of opportunities locally for example, the lack of activities such as organised walks and sports events.
3.10 PHIAC acknowledged that people with long-term conditions would usually benefit from physical activity, as it is an important independent and modifiable risk factor for numerous conditions.
3.11 PHIAC acknowledged that some people (such as those with a disability) may have fewer opportunities to be physically active than others. PHIAC recognised that adapting physical activity facilities or resources (as outlined in NICE guidance on walking and cycling [public health guidance 41]) is key to encouraging these groups to get involved. It also noted that knowledge of opportunities for such activity, for example, knowledge of leisure centres that have facilities for people with a disability, is another example of how this could be achieved.
3.12 PHIAC noted concern from some stakeholders about the use of the general practitioner physical activity questionnaire (GPPAQ) for assessing physical activity levels. It acknowledged that a number of other methods could potentially be used, however, no evidence was available to consider these. PHIAC supported use of GPPAQ as a validated tool developed to support brief interventions. It also noted that training in the use of GPPAQ was available.
3.13 The majority of studies are not from the UK. However, PHIAC considered that most of the evidence was sufficiently applicable to inform the recommendations.
3.14 PHIAC noted that brief advice has a modest, but consistent, effect on physical activity levels.
3.15 PHIAC considered that the evidence was insufficient to make recommendations about the differential impact of brief advice based on duration of delivery, content or by who delivers it.
3.16 There is a lack of evidence on the impact of the current infrastructure, processes and systems on both the delivery and uptake of brief advice. These include: the national physical activity care pathway Let's get moving (DH 2009); and incentive systems such as QOF indicators HYP004 and HYP005.
3.17 Data on the effectiveness of brief advice, compared to usual care (that is, not receiving brief advice), were specified in terms of the probability of moving from an inactive state to an active state 1 year later. PHIAC noted that the incremental cost-effectiveness ratio (ICER) of brief advice was £1730, compared with usual care. Thus, brief advice can be considered cost effective. PHIAC thought this was a conservative estimate.