Versus Arthritis – Written evidence (NPS0042)

1. Versus Arthritis welcomes the opportunity to respond to the Lords Select Committee’s National Plan for Sport and Recreation inquiry.[1]
2. Versus Arthritis is the charity formed by Arthritis Research UK and Arthritis Care joining together. We work alongside volunteers, healthcare professionals, researchers, and friends to do everything we can to push back against arthritis. Together, we develop breakthrough treatments, campaign for arthritis to be a priority and provide support. Our remit covers all musculoskeletal conditions which affect the joints, bones and muscles including osteoarthritis, rheumatoid arthritis, back pain, and osteoporosis.[2]
3. Arthritis and related musculoskeletal conditions affect 18.8 million people in the UK and are the single biggest cause of pain and disability in the UK. Cumulatively, the healthcare costs of osteoarthritis and rheumatoid arthritis will reach £118.6 billion over the next decade.[3] Musculoskeletal conditions account for a fifth of all sickness absence and result in the loss of around 28.2 million working days to the UK economy each year.[4]
4. This submission provides an overview of the work Versus Arthritis has done to support individuals who have musculoskeletal conditions to become and remain physically active at a level that’s right for them in a wide range of settings. Our evidence focuses on the following questions included in the scope of the inquiry:

• How can local delivery, including funding structures, of sport and recreation be improved to ensure that people of all ages and abilities are able to lead an active lifestyle?
• How can adults of all ages and backgrounds, particularly those from under-represented groups, including women and girls, ethnic minorities, disabled people, older people, and those from less affluent backgrounds, be encouraged to lead more active lifestyles?
• Sporting Future: A New Strategy for an Active Nation, the Government’s 2015 sports strategy, outlines five outcome priorities: physical health, mental health, individual development, social and community development and economic development. Are these the right priorities and how successful has the government been in measuring and delivering these outcomes to date?

5. Summary points:
• Physical activity is vital for both maintaining good musculoskeletal health in the general population, and helping people with musculoskeletal conditions manage their condition to prevent further pain and disability.
• The COVID-19 pandemic and the subsequent drop in physical activity levels is likely to have a long-term negative impact on people’s musculoskeletal health, and could result in an increased prevalence of musculoskeletal conditions.
• A National Plan for Sport and Recreation needs to provide tailored support for people with existing musculoskeletal conditions, and address the additional barriers to staying active they report.
• The delivery of physical activity programmes needs to be done using a whole system, place-based approach, with a focus on collaborative working, community co-design, and building on the assets which already exist at a local level.
• Digital health tools can be effective in providing tailored support which addresses the barriers people with musculoskeletal conditions experience, but must be developed alongside in-person programmes, rather than as a replacement.
• Proactive positive messaging, especially from healthcare professionals, is needed to give people with musculoskeletal conditions the confidence and knowledge to exercise safely.
• National funding bodies should work with health charities to identify and distribute Government funding to exercise initiatives and pilot schemes that are designed to reach disadvantaged communities and reduce health inequalities.
• The Government’s approach to measuring success should take into account the long-term savings in healthcare costs which will be delivered by increasing physical activity levels in people with musculoskeletal conditions. The Government should also try to better understand and measure people’s motivation around exercise in order to promote long-term behaviour change.

Prevalence and impact of musculoskeletal conditions in the UK

6. Musculoskeletal conditions affect an estimated 18.8 million people in the UK.[5] While people at any age can develop musculoskeletal problems, the most common musculoskeletal condition, osteoarthritis, is increasingly prevalent with age. 
7. Musculoskeletal conditions are the highest single contributor to disability, both globally and in the UK.[6] In 2017, musculoskeletal conditions accounted for over 22% of reported morbidity in the UK, with lower back pain being the largest cause of ill health across all ages.6
8. Limited mobility, limited dexterity, pain and fatigue are common symptoms of musculoskeletal conditions; 78% of people living with arthritis report experiencing pain most days, and over half say they are in pain every day.[7]  In addition to chronic pain, people with musculoskeletal conditions are also more likely to suffer from mental ill health and generally report a lower quality of life.[8],[9]

The link between musculoskeletal conditions and physical activity

9. Regular physical activity is a key part of maintaining good health, and the National Institute for Health and Care Excellence (NICE) has acknowledged the role that exercise plays in preventing and managing over 20 different illnesses.[10]
10. Doing an appropriate level of physical activity, is one of the most effective ways to prevent musculoskeletal problems. Regular physical activity can reduce joint and back pain by 25%, and reduce the likelihood of impairment in walking and daily activities by a third.10
11. Exercise is also key for many people who already have a musculoskeletal condition in helping them manage their pain and prevent further disability. Physical activity can help reduce pain, improve mobility, and reduce stiffness, making it a key treatment for some of the most common musculoskeletal conditions, including osteoarthritis and chronic back pain.[11], [12]
12.          However, our own research has highlighted the wide range of barriers that people with musculoskeletal conditions face when trying to stay physically active. A survey we conducted in November 2019, involving over 800 people with musculoskeletal conditions found:[13]
• Only 29% of people surveyed met the Sport England definition of ‘active’.
• 7 in 10 said that they would like to be more active.
• Over half said that they would find it difficult to become more active, with their musculoskeletal condition being the key perceived limiting factor for most people (often due to pain or fatigue).
• 77% reported wanting practical support such as tips about activity and pain management to help them exercise more.
• Only 56% said that their local leisure centre was nearby and accessible, a quarter of respondents say that a ‘lack of local facilities’ limits their activity levels.
• A quarter reported that they had been told at least once that physical activity would make their condition worse.

The impact of COVID-19 on physical activity and people with musculoskeletal conditions

13. The impact of the COVID-19 pandemic and the subsequent restrictions placed on daily life have made it significantly more difficult for people, including those with musculoskeletal conditions, to stay physically active.
14. According to analysis by the Scientific Advisory Group for Emergencies (SAGE), the impact of COVID-19 and restrictions is likely to lead to more people starting to develop musculoskeletal pain, and in the long-term, an increased prevalence of musculoskeletal conditions.[14]
15.          This aligns with our own research, conducted in August 2020 and involving over 1000 people, on the impact of working from home due to the pandemic on people’s musculoskeletal health and physical activity, which found:[15]

• 48% of those surveyed admit they are less physically active now than when lockdown was first put in place.
• One in four (27%) admitted to taking less care of their physical and mental health compared to before lockdown.
• 81% of respondents reported experiencing new musculoskeletal pain, with lower back pain being the most common complaint (reported by 50% of respondents).

16. In October 2020, we conducted research through our campaigner network and collated the responses from over 1,500 people with musculoskeletal conditions about their concerns around the impact of the ongoing pandemic:[16]

• 74% of respondents reported that they were worried about the impact of the pandemic on their physical health and managing their pain.
• 69% said they were worried about the impact on their mobility and staying active.
• 31% of respondents were most concerned about accessing leisure facilities including gyms and swimming pools.

17.          Survey research from the Richmond Group of Charities conducted in June 2020 in partnership with Sport England, found that:[17]

• During the height of the first lockdown restrictions, 4 in 10 people with long-term health conditions (LTHCs) reported doing less physical activity than normal.
• Since the beginning of lockdown restrictions in March, a quarter of people with LTHCs have not been doing 30 mins of physical activity on any day over the course of a week.
• Even as lockdown restrictions eased, 55% of people with LTHCs said that they still worried about leaving their home to do exercise or be active (data from mid-May 2020).
• Attitudes around capability, opportunity, and motivation to do physical activity have been significantly lower for people with LTHCs during the pandemic compared to people without a health condition.

18.          Lower levels of physical activity as a result of COVID-19, increases the risk of musculoskeletal deconditioning in the general population. For people who already have musculoskeletal conditions, lower levels of physical activity are likely to have knock-on effects, such as increasing levels of pain and a potential deterioration in mental health.
19.          While COVID-19 pandemic restrictions are still in place, the Government needs to provide more support and resources to enable people to stay physically active. Vulnerable groups who are at increased risk of deconditioning, including people with existing health issues and individuals who have been shielding, should have access to additional support to help them exercise safely. 
20. In order to fully understand the impact of COVID-19 on people’s health and to design services according to the level of need at a local and national level, information on the prevalence and impact of musculoskeletal conditions needs to be collected and included in all COVID-19 recovery plans relating to the provision of physical activity services.
21. A National Plan for Sport and Recreation needs to take into account the significant negative impact COVID-19 has had on musculoskeletal health, and address the barriers people with existing musculoskeletal conditions face when trying to stay active. 

How a National Plan for Sport and Recreation can support and promote musculoskeletal health

How can local delivery, including funding structures, of sport and recreation be improved to ensure that people of all ages and abilities are able to lead an active lifestyle?

22. Versus Arthritis, in partnership with Public Health England, the Department of Health and NHS England, developed a commissioning toolkit to support the provision of physical activity interventions for people with musculoskeletal conditions. This report should be used to help design physical activity resources which are accessible for people with musculoskeletal conditions at a local level.10   
23. A whole system approach to promoting physical activity is needed to reach people with musculoskeletal conditions, with a focus on providing a range of options for building activity into daily life, taking into account people’s varying levels of physical limitation and pain.
24. This approach is supported by Public Health England’s 2020 guidance on the role of physical activity in prevention and management of long-term conditions, which stated ‘It is of increasing importance to take a whole systems approach to addressing public health challenges, including physical inactivity and obesity. Local government plays an important leadership role in bringing together statutory, voluntary and private sectors and engaging their populations to build confident and connected communities as part of efforts to improve health and reduce health inequalities.’[18]
25. A successful integrated approach to local delivery requires a much greater level of collaboration between different parts of the healthcare system, the leisure sector, local authorities, and charity partners, who all play a role in supporting physical activity for people with health conditions.
26. Within our own work in delivering physical activity programmes, Versus Arthritis has collaborated with Active Partnership organisations, Local Delivery Pilots, National Governing Bodies across a number of sports, clinical commissioning groups (CCGs), Local Authorities and Social Prescribing services. These partnerships have allowed us to develop a wide range of programmes, tools, and behaviour change care pathways to promote physical activity amongst people with musculoskeletal conditions.
27.          While collaboration is vital, it is also important to recognise the challenges in developing shared goals and outcomes which work for all the stakeholders involved. New, innovative ways of partnering are needed, that allow each organisation to reach their goals while maximising the benefit delivered to the community.
28. With regards to the delivery of physical activity programmes at scale, especially those that are developed collaboratively, it’s important that pilot schemes are given enough time and resources to build up and become embedded in the community in order to be effective.
29.          Place-based design is key in delivering physical activity programmes at a local-level, with a focus on building upon the pre-existing strengths within a community and identifying existing resources that can be utilised in new ways. This aligns with the ‘strengths-based approach’ implemented by the National Lottery Community Fund, and Sport England’s aim to expand their place-based working as outlined in their new ten year vision, ‘Uniting the Movement’.
30. A place-based approach has been successful in a number of our existing exercise initiatives. For example, when developing ‘Get Active for Arthritis’, a physical activity management course for people living with musculoskeletal conditions across mid and north Wales, understanding and adapting to existing services in each locality has helped with recruitment and retention of participants and volunteers. Our work partnering with Paths for All to develop walks for people with musculoskeletal conditions in their local area similarly demonstrates how local initiatives can collaborate with health charities to make their activity programmes more inclusive and accessible.
31. Locally led physical activity programmes could be improved by integrating more community involvement and co-design into their development process, with a specific focus on seeking input from people with existing health conditions and disabilities. Versus Arthritis’ Living Well Service provides local touchpoints for people with musculoskeletal conditions to receive support, including physical activity programmes, that are led by our volunteers and tailored to the needs of the community. Allowing people with musculoskeletal conditions to shape physical activity strategies, can help ensure barriers to exercise for these individuals are identified and addressed.
32.          For people with musculoskeletal conditions, digital tools and platforms can be important in  supporting people to exercise, regardless of their ability. In our research on the needs of people with musculoskeletal conditions in being physically active, we found:13
• 55% of respondents wanted internet-based support.
• 46% wanted access to online forums on physical activity.
• Over half (57%) were interested in digital tools to help become more active​, with the highest levels of interest being around wearable technologies or video-based tutorials.
33. In response to COVID-19, Versus Arthritis developed a digital exercise programme Let’s Move with Leon, which provided people with movement sessions covering strength, flexibility, and cardiovascular fitness, along with weekly emails, videos, an activity hub, and peer-to-peer support through our online community and social media platforms.
34.          Since launching the Let’s Move with Leon programme:[19]
• 29,600 individuals have signed up to the programme.
• The most common motivation of participants was to ‘improve management of [their] condition’. 
• 30% of participants were living with chronic long term joint pain.
• 34% of participants were diagnosed over five years ago.
• 63% of participants who had a long-term health condition were previously inactive at the start of the programme.
35. However, digital support tools will not be appropriate for every person experiencing barriers to exercise, and technology should be integrated into local delivery to enable the solution, rather than to be the solution itself. In-person peer support and exercising in groups will always be transformative for some people, and it is important that any digital strategies align with the in-person activities being delivered at a local-level, to prevent silos developing.

How can adults of all ages and backgrounds, particularly those from under-represented groups, including women and girls, ethnic minorities, disabled people, older people, and those from less affluent backgrounds, be encouraged to lead more active lifestyles?

36.          Versus Arthritis research into the attitudes and experiences of people with musculoskeletal conditions around physical activity, conducted in November 2019, indicated that:13
• Healthcare professionals were the key source of information for most respondents, with 70% saying they were their main source of advice and support.
• Less than half (48%) of respondents thought of physical activity as good for managing their joint pain or arthritis.
• 25% of respondents reported being advised that physical activity would make their condition worse, with this advice most commonly coming from consultants, GPs, or physiotherapists.
• People who thought that health professionals would approve of them doing physical activity, were more likely to be active in practice.
• For those people with musculoskeletal conditions who were active, their key motivators were increased fitness and the mental health benefits of activity.
37. In order to give people with musculoskeletal problems the confidence to stay active, there needs to be strong messaging from across the sector promoting exercise as an effective tool for building and maintaining good musculoskeletal health.
38. In line with this messaging, physical activity providers should work with clinical experts and patient charities to develop practical advice on how to manage symptoms, including pain, that without support may limit people’s ability to exercise.
39. The ‘We are Undefeatable’ Campaign, which is a project led by the Richmond Group of Charities with support from Sport England, is a successful example of how sharing tailored messaging and support for people with long-term health conditions can enable more people to become physically active.    
40. Promoting real life stories of people with health conditions or disabilities is a highly effective way to motivate and empower similar individuals who are trying to become more active. For example, in our work promoting ESCAPE-pain, a platform designed to help manage lower-limb arthritic pain through exercise, highlighting personal experiences from our community has been key to building a compelling case for change.
41.          For people with existing health conditions like musculoskeletal problems, encouragement from HCPs to stay physically active is highly motivating. As highlighted by our research, a significant number of people with musculoskeletal conditions are currently receiving conflicting messages from their HCPs about the value of staying active, and how they can exercise safely with their condition.
42. More work needs to be done across the sector to tackle the misconceptions that exist around pain and physical activity, and highlight to HCPs how musculoskeletal pain can be exacerbated by sedentary behaviour. Building positive working relationships between activity providers, volunteer-led exercise programmes, and local health systems, will help HCPs feel confident in providing positive and supportive advice about exercise to people with musculoskeletal conditions, and referring them to activity support as needed.
43. The Make Every Contact Count and Moving Medicine initiatives both provide valuable resources for HCPs on how they can integrate exercise promotion into clinical care. Both national and local health systems should be signposting HCPs to these resources in order to support them in initiating conversations about physical activity with people who have musculoskeletal conditions.
44. To prevent widening inequalities in both musculoskeletal health outcomes and physical activity, exercise programmes for people with musculoskeletal conditions must also address the additional barriers to becoming active people may experience. Research carried out by Sport England has highlighted how people from Black, Asian minority ethnic groups and lower socio-economic groups are less likely to meet the Chief Medical Officer’s threshold to be considered active.[20], [21]
45.          Working with healthcare charities who have experience supporting people with existing health conditions to exercise can be an effective way to reach communities who are also less likely to engage with traditional exercise services.
46. Versus Arthritis is currently partnering with Sport England to help distribute grants from their ‘Tackling Inequalities’ fund to provide targeted, intersectional support to people with long-term health conditions, Black, Asian minority ethnic groups, and lower socio-economic groups.[22]

Sporting Future: A New Strategy for an Active Nation, the Government’s 2015 sports strategy, outlines five outcome priorities: physical health, mental health, individual development, social and community development and economic development. Are these the right priorities and how successful has the government been in measuring and delivering these outcomes to date?

47.          We support the priority outcome included in the Government’s 2015 strategy to improve physical wellbeing through decreasing the percentage of the population that are physically inactive.[23] Given the high prevalence of musculoskeletal conditions in the UK, removing the barriers to participation that can arise from having a musculoskeletal condition must be a key consideration of any national strategy in order to deliver on this priority. The Government should include a specific ambition to increase physical activity amongst people with musculoskeletal conditions as part of how they measure success going forward.  
48.          We know that interventions which are successful in supporting higher levels of physical activity amongst people with musculoskeletal conditions can help prevent further deterioration in their health and, as a result, indirectly deliver cost savings to the health service. Given that the treatment of musculoskeletal conditions is the third biggest area of annual NHS spend, these savings should be included in the Government’s economic assessment of the benefits provided by higher levels of physical activity in people with musculoskeletal conditions.[24]
49.          Across our work promoting physical activity to people with musculoskeletal conditions, understanding what motivates individuals to become and stay active has been key to delivering long-term behavioural change. Developing a better understanding of what effectively motivates different communities, especially people with long-term health conditions, and increasing people’s motivation to be active, should be part of how the Government measures success om this area.

28 January 2021