Primary Care Referral Interventions for Health Improvement
Submitting InstitutionUniversity of Gloucestershire
Unit of AssessmentSport and Exercise Sciences, Leisure and Tourism
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Research undertaken by Professor Diane Crone, Professor David James
and co-researchers has investigated the use of physical activity and art
promotion interventions in health care, as an adjunct to treatment, to
improve patient health and wellbeing. The research has had policy,
practice and patient benefit. The specific areas upon which it has
(i) Guidelines and practice for intervention development;
(ii) Professional development of health and physical activity
professionals in the UK and throughout Europe;
(iii) Public and patient health and wellbeing improvements.
The research is a product of commissioned or grant funded evaluation of
policy, practice and outcomes in the area of health referral in primary
care. The specific areas of focus are physical activity/exercise referral,
and art referral. The research is summarized below.
Physical activity referral research
This includes large scale population-based exercise referral schemes in
Somerset (1999-2005), Greenwich (2005-2009) and South Staffordshire
(2009-2010). The research focussed on factors associated with patient
uptake, attendance and completion of the three independent schemes. The
research comprised a series of contracts awarded to the University of
Gloucestershire (Crone, James and Johnston) following
competitive tendering processes. These contracts also included
commissioned staff training and development, and quality assurance work.
The research contributed to a number of empirical findings (1, 2) and
practice-related findings (3, 4, and 5). As such, it has helped develop a
thorough understanding of the factors associated with patient engagement
(uptake, attendance and completion) including referral reason, age, gender
(4, 5) and a focus on complex socio-demographic factors, their measurement
and association (2, 3). In addition, and most substantively, the research
predominantly used an ecologically valid observational design to determine
factors associated with uptake and attendance outcomes (3, 4, and 5). The
primary findings were that factors associated with successful uptake and
completion include gender (more women take up, more men complete), age
(older), referral reason (physical reasons) and social-economic position
(less deprived). Mixed method research involving patients, referrers and
deliverers also confirmed the holistic multidimensional nature of
`success', rather than traditional notions of weight loss and blood
Art referral research
Involved developing evidence of effectiveness of a county scheme in
Gloucestershire, commissioned by the County Council and NHS (2007-2013).
The research team (Crone, James and Tyson) contributed to
the design, implementation and evaluation of an art referral intervention
based in primary care. The intervention targeted patients with
mild-moderate mental health problems and adopted a rigorous process and
outcome evaluation design not previously used in art referral
interventions. Research revealed the success of the intervention for
patients and practitioners (clinicians, commissioners and artists) who
identified the intervention as an alternative holistic option for the
treatment of mental health problems (6). Significant improvements in
mental wellbeing for patients were also found, with factors associated
with positive engagement identified as gender (women), age (older) and
more deprived socioeconomic groups.
The applied nature of this research has resulted in the research team
being involved in intervention and pathway design, in addition to
evaluation. This has been complemented by the inclusion of the research in
training materials for professionals involved in such interventions and
national policy recommendations.
To date Crone has published 48 articles, undertaken over 30
commissioned UK based research projects and secured two large EU grants
totalling over a £1 million, co-authored one book, written five book
chapters, and presented nationally and in the EU. Publications selected as
the basis for the present impact are drawn from physical activity referral
research dating back to 1999 and arts referral research dating back to
References to the research
Articles that have been published relating to the case study have been
cited 521 times (464 since 2008) [ref: Google Scholar 23.11.13]. The case
study is underpinned by the following peer reviewed publications:
1. Gidlow, C., Johnston, L.H., Crone, D., James, D.V.B.
(2005) Attendance of Exercise Referral Schemes in the UK: a systematic
review. Health Education Journal. 64 (2): 168-186 http://dx.doi.org/10.1177/001789690506400208
(Journal Impact Factor: 0.929, cited= 45).
2. Gidlow, C., Johnston, L.H., Crone, D., Ellis, N., James,
D.V.B. (2006) A systematic review of evidence of the relationship
between socio-economic position and physical activity. Health
Education Journal. 65: 338-367 http://dx.doi.org/10.1177/0017896906069378
(Journal Impact Factor: 0.929, cited= 93).
3. Gidlow, C., Johnston, L.H., Crone, D., Morris, C., Smith, A.,
Foster, C., James, D.V.B. (2007). Socio-demograhic patterning of
referral, attendance and uptake in physical activity referral schemes. Journal
of Public Health, 29 (2): 107-113. (Journal Impact Factor: 1.993,
4. James, D.V.B., Johnston, L.H., Crone, D., Sidford,
A.H., Gidlow, C., Morris, C., Foster, C. (2008). Factors associated with
physical activity uptake and participation. Journal of Sport Sciences,
26 (2), 217-224. http://dx.doi.org/10.1080/02640410701468863
(Journal Impact Factor: 2.082, cited= 30)
5. Crone, D., Johnston, L., Gidlow, C. Henley, C. and James,
D (2008). Uptake and Participation in Physical Activity Referral
Schemes in the UK: An Investigation of Patients Referred with Mental
Health Problems. Issues in Mental Health Nursing, 29: 1088-1097. http://dx.doi.org/10.1080/01612840802319837
(Journal Impact Factor: 0, cited= 19)
6. Crone, D., O'Connell, E.E., Tyson, P.J., Clark-Stone, F.,
Opher, S. and James, D.V.B. (2012). `It helps me make sense of the
world'; The role of an art intervention for promoting health and wellbeing
in primary care: Perspectives of patients, health professionals and
artists. Journal of Public Health. 20 (5): 519-524. http://dx.doi.org/10.1007/s10389-012-0495-x
(Journal Impact Factor: 1.993, cited= 0)
Details of the impact
The reach of the research is wide and includes policy makers (national
and EU), public health commissioners, local government leisure and
exercise officers, leisure providers, primary care health professionals
(general practitioners, nurses), fitness instructors and patients/the
public. The impact is summarized below:
a. Impact on applied practice and policy/national recommendations
Practice has been influenced at local, regional, national and international
levels, and the influence extends to commissioners, health practitioners,
physical activity and art specialists, and patients/public themselves. The
research has informed the development of policy in the form of toolkits and
recommendations, which has resulted in more bespoke and informed
commissioning and subsequent intervention design. This impact is not just
the result of a linear and consecutive research-practice pathway/process;
rather, over the fifteen year period practice has also informed and driven
the research according to the needs of those commissioning the research and
This is evidenced by the following:
i. Provided consultancy on effective physical activity promotion in the
EU in both Spain (Regional Government Department of Sport and Physical
activity in Castilla-La Mancha) (2012) (Corroborating source A)
and in the Czech Republic (2010).
ii. Worked with the British Heart Foundation National Centre for Physical
Activity and Health in the development of the Exercise Referral Toolkit
(see - http://www.bhfactive.org.uk/sites/Exercise-Referral-Toolkit/index.html)
published in 2011 (Corroborating source B).
iii. Member of a cross-sector working group of clinical, commercial and
third/sector-public organisations who developed the `Active Planning
Toolkit' (see - http://www.nice.org.uk/media/sharedlearning/326_nhsglos_nhs_uk.pdf)
to facilitate implementation of the Centre for Public Health Excellence
(NICE) "Promoting or Creating Built or Natural Environments that Encourage
and Support Physical Activity" (2008) guidelines. The toolkit is
recognised by NICE as having a significant impact to the work in this area
going forward (Corroborating source C).
iv. Presented at national conferences on physical activity pathways in
2010 (62 health professionals attended) (Corroborating source B)
and regional public health conferences for art on referral in 2012 (South
West) and 2013 (Milton Keynes) (Corroborating source D).
v. Part of a group to develop a `Commissioning Resource for Physical
Activity, Mental Health and Wellbeing and Food and Nutrition for the North
West of England' (see - http://www.nwcommissioning.org/planning-for-commissioning/commissioning-for-
for NHS North West, 2010-2011.
vi. Adoption of the evaluation processes and documentation developed by
Crone in the Art Lift, Gloucestershire project by the Bristol Art Shine
referral programme (Corroborating source D).
vii. Testimonies from public health and clinical professionals on the
impact of research on subsequent commissioning decisions in the area of
art and physical activity referral interventions (Corroborating sources D,
E, F, G).
b. Impact on professional development
The research has influenced the professional development of exercise
instructors across the UK and health professionals (doctors, nurses,
public health practitioners) across the UK and EU.
This is evidenced by the following:
i. Authored chapter and related course tutor slides and notes in the
British Association for Cardiac and Pulmonary Rehabilitation (BACPR)
exercise instructor manual; the resource for exercise instructors on the
national BACPR Phase IV exercise instructor course. Nine regions use the
manual, including Scotland, Northern Ireland and Wales, with approximately
250 instructors being trained per year (Corroborating sources B, H).
ii. Content for the In2Health's UK wide professional development
programme for clinicians (1200 clinicians attended per annum) includes the
research (Corroborating source I).
iii. Professor Crone was the lead for the EU Leonardo Funded Healthy
Europe through Learning and Practice (HELP) project (see - http://www.help-project.com/3/2/WHAT-IS-
which has developed an online CPD resource for health professionals across
6 EU countries. Initial impact from the needs analysis and piloting of the
resource identifies that over 300 EU based health professionals have been
involved in its development and piloting. Longer term impact will be known
after the product is launched November 2013 (Corroborating source A,
iv. A central part of many of the commissioned evaluations has involved a
training element for staff involved in the delivery of these interventions
such as physical activity and health referral professionals.
v. Crone is co-author of text book; Physical Activity and Health
Promotion: Evidenced- based Approaches to Practice (2009).
c. Impact on patient benefit
The research has impacted on patients through improving practice and
striving for evidenced based practice in primary care.
This is evidenced by the following:
i. The applied interventions that underpin this case study have involved
over 6000 patients, thereby having a direct impact on these individuals
and their families within the community.
ii. Many of the commissioned evaluation research projects have included
the design of interventions enabling an evidenced based approach to
intervention design. The aim is to improve the effectiveness of such
interventions and thus improve individual patient uptake, attendance and
completion, leading to improved health outcomes (Corroborating sources B,
D, H, G).
iii. The BACPR course, taken by approximately 240 fitness instructors per
annum, each required to read the chapters contributed by Crone
(Corroborating source H). These instructors teach approximately
2-3 classes a week with approximately 20-30 patients in each class.
Crone's chapter and tutor resource on psychological considerations for
cardiac patients will inform their practice daily. The impact on patients
is therefore estimated at 6000-9000 per annum in the UK (Corroborating
iv. Crone's input into the content of three toolkits (two national, one
regional - exercise referral, use of the built environment for physical
activity and a commissioning resource) will have an impact on patients via
the evidence based interventions informed by these documents
(Corroborating source C).
Sources to corroborate the impact
A. Reader, Health and Exercise, Universidad de Castilla-la Mancha,
B. Primary Care Project Manager, BHF National Centre for Physical
Activity & Health
C. Director, Centre for Public Health Excellence, NICE
D. Health Improvement Commissioner, Gloucestershire County Council
E. Strategic Commissioner for Sexual Health and Well-being,
F. General Practitioner, Gloucestershire.
G. Public Health Specialist, Somerset County Council
H. Education Director, British Association for Cardiac and
Pulmonary Rehabilitation (BACPR)
I. Consultant Physiologist (cardiology), Gloucestershire