GPA0002

Written evidence submitted by Richmond Group of Charities

About the Richmond Group of Charities

1. The Richmond Group is a coalition of health and care charities working together to help people living with long-term, multiple or complex health needs to live well and thrive[1]. We represent over 15 million people living with long-term conditions who we know face common challenges to live well. Our priorities focus on inequalities in access, experience and outcomes for them, and on tackling those common challenges they face.

2. Richmond Group members work together as part of the Movement for All programme, in partnership with Sport England as a System Partner under the Uniting the Movement strategy. The programme supports people with long-term conditions to become and remain physically active by tackling the barriers in the system that prevent them. Sport England also supports and provides National Lottery funding for We Are Undefeatable[2], a public campaign led by Richmond Group members and other charity partners that aims to inspire and encourage people with long-term conditions to move more.

3. We are submitting this response to share insights we have developed into the barriers facing people with long-term conditions to being more physically active, as well as learning from our partners’ programmes that have sought to reduce inactivity among people living with single and multiple conditions. We hope our evidence will inform the committee’s inquiry by highlighting how the needs and experiences of this audience in participating in sport and physical activity. We would be delighted to provide further information relating to any of the points raised in this submission.

Summary

4. This response give evidence in relation to the following points:
    

1. People with long-term health conditions face specific barriers to being physically active. These barriers must be overcome with measures by policymakers, funders, the health and care sector and the sports and leisure sector to increase participation, reduce inequalities and reap the benefits for individuals and for communities and society.
2. The Richmond Group and Sport England are working in partnership on measures to bring about change for people with long-term conditions and their motivation for, access to and experience of physical activity.
3. Measuring the success of interventions should take into consideration changes in behaviours, resilience and adaptability among participants, as well as the health and wellbeing and wider benefits of physical activity. As such, measuring the success of a grassroots sport and physical activity strategy cannot solely focus on participation numbers, which don’t adequately capture the nuances of progress.

i. People with long-term health conditions face specific barriers to being physically active. These barriers must be overcome with measures by policymakers, funders, the health and care sector and the sports and leisure sector to increase participation, reduce inequalities and reap the benefits for individuals and for communities and society.

5. In England, 43% of the adult population has at least one long-term health condition, and they are twice as likely to be inactive as those without. Such conditions might include depression, anxiety, dementia, type 2 diabetes, back pain, Parkinson’s, asthma, arthritis, and cardiovascular disease.
    
6. Long-term conditions are more prevalent amongst older people. They are more common and more likely to be severe in those from lower socio-economic groups, who are also more likely to live with multiple conditions[3]. Estimates for the percentage of people living with multiple long-term conditions in England vary from 15% to 30%; in the UK this number is expected to rise to 68% in 2035[4].

7. 64% of people with long-term health conditions would like to be more active, but they face significant barriers[5]. Often these are condition-related, such as fear of making conditions worse and struggling to build a routine due to the unpredictability of their condition. However, these are compounded with barriers of lack of motivation, time, social support, and access or opportunity to visit affordable, suitable, inclusive facilities[6].

8. Research undertaken as part of the We Are Undefeatable campaign has shown that when mapped against behaviour change models (which have proven successful in encouraging participation), we see that barriers related to capability most affect the least active, people with multiple conditions and those from lower socio-economic groups. Motivational and confidence barriers particularly affect females and young people[7]. Opportunity restricts people from BAME backgrounds the most[8].  
    
9. The pandemic has made inequalities starker and exacerbated the complex web of barriers that make it harder for people with long-term conditions to be active. In 2020, 38% of people with a long-term condition cited Covid-19 as a barrier to being active[9]. In April 2022, 9% still cited Covid-19 as a barrier and 55% said they still prefer to exercise at home[10]. This has led to a decrease in strength and fitness, particularly amongst older people which OHID predicts will result in a higher number of falls, which could lead to increased hospital admissions[11].
    
10. Sport England’s Together Fund, administered by Versus Arthritis on behalf of the Richmond Group, was established during Covid-19 to support audiences whose ability to be physically active was disproportionately affected, including people with long-term health conditions. This was a welcome source of support.

11. While many people still feel more comfortable being active at home, there is an opportunity to improve the accessibility and inclusivity of the sport and physical activity sector as it continues to recover from the impact of the pandemic. Expanding the number of people able to use and feel welcome to use these services would be of direct financial benefit to providers. The sport and physical activity sector needs to address its messaging which often communicates structured sport and exercise, rather than physical activity and movement in its broad sense. This creates a barrier for people who don’t relate to this approach or perceive themselves as ‘sporty’.
     
12. A recognised quality standard for facilities and services could be helpful. Some benchmarking standards exist (such as the QuestNBS Gplus37 facilities) but they are not well-promoted to the sector or to the public. The Alzheimer’s Society Dementia Friendly Guide, funded by Sport England, is an example of how person-centred approaches can improve services and facilities for a wide range of people, and need not be large or expensive to have impact.  

13. There would also be great benefit in better coordination among policy professionals across sectors. Interviews with these stakeholders conducted as part of We Are Undefeatable indicated that there is some accord about the lack of integration and coordination between stakeholders invested in keeping people active. This insight is echoed by Easier to be Active research undertaken by the Sheffield Hallam University funded by Sport England. The project explored ways to help people with long-term health conditions lead a more active lifestyle. It included extensive consultation with professionals, and developed a framework and recommendations for physical activity professionals and health professionals.

14. The cost of inactivity is estimated at £7.4 billion annually, not just through its contribution to ill health and healthcare costs, but also by reducing the health and productivity of the workforce[12]. In addition, it has been estimated that sport and physical activity in the community generate £9.5 billion of value through improved mental and physical health, including £5.6 billion of healthcare savings and £1.7 billion of social care savings[13]. Tackling inactivity among people with long-term conditions creates opportunities for potential health and care efficiencies as those with health conditions make up 70% of the total health and care spend in England, 64% of outpatients appointments, 50% of GP appointments and 70% of inpatient stays[14]. And yet the evidence indicates that physical activity can support self-management of a variety of symptoms and conditions, improve quality of life, maintain independence and functional ability and enhance wellbeing and prevent secondary conditions.

ii. Richmond Group and Sport England are working in partnership on measures to bring about change for people with long-term health conditions and their motivation for, access to and experience of physical activity.

15. The Richmond Group and Sport England have long enjoyed a productive working relationship. Sport England has enabled interventions across the Richmond Group to tackle cross-cutting challenges, and has had significant impact in understanding and meeting the needs of people with long-term conditions.

Movement for All

16. Movement for All aims to help people with long-term conditions to become more active in a way that suits them and improve awareness of the benefits of and barriers to physical activity. To achieve these goals, it brought together charities to build insights into physical inactivity in people with long-term conditions, to test different ways to increase physical activity, and to understand what more could be learned through a collaborative approach.

17. Evidence from across the programme demonstrates that it has achieved impact in three main areas: increased physical activity amongst people with multiple long-term conditions taking part in projects and being active at home; increased focus on physical activity as a wellbeing approach, and using evidence to shape and improve interventions; and more partnerships, increased influence with key stakeholder groups and new public narratives about physical activity and health.
     
18. Through the first phase of the programme (2018-2021), we generated a wealth of learning including how to shift attitudes and behaviours to more active lifestyles, how to effectively measure the impact of physical activity on people’s health and wellbeing, and how to work as a valuable coalition. More details can be found in the full final evaluation report[15].

We Are Undefeatable

19. We Are Undefeatable is a movement supporting people with a range of long-term health conditions, backed by expertise, insight and significant National Lottery funding from Sport England. Its purpose is to support and encourage people to find ways to be active that work for them.
     
20. The campaign is inspired by, and features, the experiences of people with long-term conditions getting active despite the unpredictability of their condition. It highlights the importance of social support in how people become and stay active, and provides motivation by showing how small amounts of physical activity can help to enjoy the little things in life more.
     
21. The campaign has reached three-quarters of our target audience across various channels. As part of the campaign, bespoke video routines have been created as a resource for the audience to get started with physical activity at home. Following audience insight during Covid-19, the videos were made available on DVD so people who might not have digital access could still benefit. These are now being used in care homes and borrowable from libraries as well as in private homes. The next stage of the campaign will build on the awareness raised and look to provide more practical ways the audience can get active in their local area or at home.
     
22. Using peer to peer messengers as storytellers from a diverse range of backgrounds combined with a non-traditional communication style (e.g. avoiding the terms ‘sport’ or ‘fitness’) has proven a successful approach, as well as our focus on achievable action defined by an individual rather than structured sessions defined by us. Our inclusive campaign messaging and imagery has resulted in 50% of our audience taking an action as a result of seeing the campaign[16]. We have found this approach specifically resonates with people who have been shielding (64%), who come from BAME backgrounds (71%), or who are in lower socio-economic groups (63%)[17].

23. We are working with stakeholders across the health and physical activity sectors respectively to promote use of the audience insights and tailored inspirational messaging and imagery. Doing this in tandem with improving the accessibility and inclusivity of activity facilities and provision, as well as enhancing staff training and the diversity of the workforce, would engage wider populations of people, not just inactive people living with long term health conditions.

Medical Consensus Statement on Risk

24. A significant step towards addressing a barrier for people with long-term conditions was the Medical Consensus Statement on Risk, published in 2021 by the Faculty of Sport and Exercise Medicine (FSEM) and funded by Sport England. This statement clarified that physical activity is safe, and challenged the need for pre-participation medical clearance for people living with stable long-term health conditions before increasing their physical activity levels. The FSEM recommend that the need for medical guidance should be determined by people living with long-term health conditions who are concerned about their symptoms, not by pre-participation screening questionnaires such as the physical activity readiness questionnaire (PAR-Q) or health commitment statement – a view echoed by the World Health Organisation in their 2020 Physical Activity Guidelines. It will take time to understand the impact on participation, but it addresses both individual barriers for people with long-term conditions (57% look to the NHS and health professionals for advice to be active[18]), as well as systemic barriers for the sport and physical activity sector (as opposed to turning people away on safety grounds) and also health professionals who have limited training on physical activity and limited time for unnecessary administration.
     

iii. Measuring the success of interventions should take into consideration changes in behaviours, resilience and adaptability among participants, as well as the health and wellbeing and wider benefits of physical activity. As such, measuring the success of a grassroots sport and physical activity strategy cannot solely focus on participation numbers, which don’t adequately capture the nuances of progress.

25. Movement for All provided significant insights into how to measure success appropriately when trying to increase levels of physical activity among people with long-term health conditions. In keeping with the programme’s evaluation framework, intervention projects used a number of standardised validated measures to track impact, alongside other quantitative and qualitative approaches.

26. A number of data collection challenges were reported by intervention projects. Most projects found that standardised physical activity measures were not always appropriate due to how they defined ‘physical activity’.

27. Data collection tools typically framed physical exercise as physical activity that results in raised breathing rates. This was not always appropriate for people with limited mobility or lung conditions. Standardised data collection tools were often not sensitive enough to record the progress of people with long-term conditions, which often took the form of small, incremental changes. They also were not always appropriate for people with conditions that affect their cognitive function, such as dementia and for this reason, in some cases our charity members opted to develop new tools in co-production with our target audience as opposed to using recognised standardised validated tools.

28. Some projects also faced challenges embedding activity questionnaires within the participant journey without deterring participants, leading to low response rates and partial completions. Collectively, these challenges meant that there was a reliance on qualitative data to understand and assess the impact of the interventions on physical activity. The benefit of this was the richness of information qualitative data provides. These challenges also hindered consistent economic evaluation across the programme, which in turn limited the ability of the programme evaluation to assess whether money and resources were used in the best way.

29. Another measure of success for physical activity initiatives is often reduced health service utilisation. While there are many benefits for individuals and for the health system in increasing physical activity, it may not always lead to a simple reduction in health service utilisation. This measure needs to be considered alongside other relevant measures such as improved quality of life, which may also have indirect system benefits.
     
30. When it comes to thinking about success measures for any strategy seeking to increase participation in sport and to reduce inequalities, we encourage the committee to take into consideration this need for nuance and flexibility. Some numerical measures – for example, minutes of physical activity per week – will not be appropriate for people with long-term conditions, and we encourage the committee to consider the many ways in which people’s lives can be improved incrementally by moving more outside the confines of structured sport and considering the non-linear reality of sustainably changing behaviour.

Concluding remarks

31. The needs of people with long-term conditions must be understood and met as part of the grassroots sport and physical activity strategy. Significant progress towards this has been made across the health and care sector and the sport and physical activity sector, and Sport England has played a crucial role in supporting this work. Such investment is vital for inclusive and accessible physical activity, which will help reduce inequalities and enable more people to move more.

August 2022