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Behaviour change

About

What is covered

This interactive flowchart covers a set of generic principles that can be used as the basis for initiatives aimed at changing people's health-related behaviours.
It also covers guidance on interventions aimed at individuals aged 16 or over. These range from single interventions delivered as the opportunity arises, to planned high-intensity interventions that may take place over a number of sessions. The behaviours covered relate to: alcohol, diet, physical activity, sex and smoking. However, the recommendations may also apply to other activities.
The recommendations should be implemented together.
They are particularly aimed at those who commission, design, investigate and deliver interventions to help people change their behaviour – or who encourage or support behaviour change as part of their role. This includes those who provide training on behaviour change.
In addition, they may be of interest to people who want to change their behaviour (for example, to stop smoking) and their families.

Updates

Updates to this interactive flowchart

10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.
18 December 2017 Changes made to structure of flowchart to reflect an evidence review of behaviour change: general approaches (NICE guideline PH6). For recommendations on planning see planning interventions and programmes.
24 March 2015 Physical activity: for NHS staff, patients and carers (NICE quality standard 84) added.

Behaviour change principles: highlights

  • Carefully plan interventions and programmes aimed at changing behaviour, taking into account the local and national context and working in partnership with recipients. Interventions and programmes should be based on a sound knowledge of community needs and should build upon the existing skills and resources within a community.
  • Equip practitioners with the necessary competencies and skills to support behaviour change, using evidence-based tools. (Education providers should ensure courses for practitioners are based on theoretically informed, evidence-based best practice.)
  • Evaluate all behaviour change interventions and programmes, either locally or as part of a larger project. Wherever possible, evaluation should include an economic component.

Definitions

Behaviour change interventions

Behaviour change interventions involve sets of techniques, used together, which aim to change the health behaviours of individuals, communities or whole populations.

Behaviour change programmes

Multi-agency, multi-packages and/or a series of related policies, services and interventions or other actions focused on broad strategic issues. Programmes can involve a suite of activities that may be topic, setting or population-based – and may involve changes to organisational infrastructures.

Behaviour change practitioners

Anyone who delivers behaviour change techniques and interventions can be a behaviour change practitioner, regardless of their professional background, as long as they have received specific training in these techniques. However, not all practitioners can deliver all interventions or techniques.

Behaviour change techniques

The term 'behaviour change technique' is used in these recommendations to mean the component of an intervention that has been designed to change behaviour, such as social support. The technique must meet specified criteria so that it can be identified, delivered and reliably replicated. It should also be observable and irreducible (behaviour change techniques are the smallest 'active' component of an intervention.) They can be used alone or in combination with other behaviour change techniques.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Equality Act 2010

The recommendations should be implemented in light of duties set out in the Equality Act 2010.

Short Text

Everything NICE has said on changing people's health-related behaviours, including interventions aimed at over 16s, in an interactive flowchart

What is covered

This interactive flowchart covers a set of generic principles that can be used as the basis for initiatives aimed at changing people's health-related behaviours.
It also covers guidance on interventions aimed at individuals aged 16 or over. These range from single interventions delivered as the opportunity arises, to planned high-intensity interventions that may take place over a number of sessions. The behaviours covered relate to: alcohol, diet, physical activity, sex and smoking. However, the recommendations may also apply to other activities.
The recommendations should be implemented together.
They are particularly aimed at those who commission, design, investigate and deliver interventions to help people change their behaviour – or who encourage or support behaviour change as part of their role. This includes those who provide training on behaviour change.
In addition, they may be of interest to people who want to change their behaviour (for example, to stop smoking) and their families.

Updates

Updates to this interactive flowchart

10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.
18 December 2017 Changes made to structure of flowchart to reflect an evidence review of behaviour change: general approaches (NICE guideline PH6). For recommendations on planning see planning interventions and programmes.
24 March 2015 Physical activity: for NHS staff, patients and carers (NICE quality standard 84) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Behaviour change: individual approaches (2014) NICE guideline PH49
Behaviour change: general approaches (2007) NICE guideline PH6

Quality standards

Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups

These quality statements are taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Physical activity: for NHS staff, patients and carers

These quality statements are taken from the physical activity: for NHS staff, patients and carers quality standard. The quality standard defines clinical best practice for physical activity: for NHS staff, patients and carers and should be read in full.

Quality statements

Designing health and wellbeing programmes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups have their views represented in setting priorities and designing local health and wellbeing programmes.

Rationale

Health and wellbeing programmes can support positive behaviour changes and contribute to promoting health and preventing premature mortality. People from black, Asian and other minority ethnic groups may not engage with services or may have a poor experience of those programmes and associated services if they are not culturally sensitive and appropriate. Involving people, community organisations and faith leaders who can represent the views of local minority ethnic groups helps to ensure that the services reflect the needs and preferences of the local population.

Quality measures

Structure
a) Evidence of work carried out to gather intelligence about the ethnic diversity of the local population.
Data source: Local data collection, for example, intelligence gathered for the Joint Strategic Needs Assessment.
b) Evidence of work carried out to gain understanding of the needs of black, Asian and other minority ethnic groups living in the local area.
Data source: Local data collection, for example, intelligence gathered for the joint strategic needs assessment.
c) Evidence of actions taken to gather views of local people from black, Asian and other minority ethnic groups on priorities for and design of health and wellbeing programmes.
Data source: Local data collection, for example, from programme planning, records from meetings (agendas or minutes) and focus groups.
d) Evidence of how intelligence on ethnic diversity, the needs and views of the local population is used to inform commissioning.
Data source: Local data collection, for example, information included in local health equality assessments.
Process
a) Proportion of local health and wellbeing programmes that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Numerator – the number in the denominator that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Denominator – the number of health and wellbeing programmes commissioned locally.
Data source: Local data collection, for example, service annual report.
b) Proportion of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes who felt that their views were valued.
Numerator – the number in the denominator that felt their views were valued.
Denominator – the number of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes.
Data source: Local data collection, for example, surveys carried out with people representing ethnic groups.
Outcome
a) Uptake of local health and wellbeing services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, service workflow.
b) Proportion of people from black, Asian and other minority ethnic groups referred to local health and wellbeing services who feel that the services meet their needs.
Data source: Local data collection, for example, service user survey.
c) Prevalence of obesity among local people from black, Asian and other minority ethnic groups.
Data source: NHS Digital’s Health Survey for England and National Child Measurement Programme, and local data collection, for example, GP practice data.
d) Physical activity levels among local people from black, Asian and other minority ethnic groups.
Data source: Active Lives, Sport England and local data collection, for example, review of service user records held by the provider.
e) Prevalence of tobacco use among local people from black, Asian and other minority ethnic groups.
Data source: Office for National Statistics’ Annual Population Survey and local data collection, for example, stop smoking service data.
f) Mental wellbeing among local people from black, Asian and other minority ethnic groups.
Data source: Local health data collection, for example mental health and wellbeing joint strategic needs assessment profile.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that the services they provide recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups. They continually review the services to ensure that they are culturally appropriate, accessible and tailored to the diverse needs of the local population.
Health, public health and social care practitioners recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups that they support. They ensure that the services they provide are culturally appropriate and accessible. This may mean working in partnership with existing local community groups or faith leaders who can support delivering some of the programmes in non-traditional community-based settings.
Commissioners (Public Health England, NHS England, local authorities, clinical commissioning groups) gather intelligence and gain understanding of the diversity of the local population and its needs. They ensure that the views of people from minority ethnic groups are represented when priorities are set and local health and wellbeing programmes are designed. This may be through engaging local communities using public consultation or community workshops that discuss future services. These can ensure that the local population is represented by individuals as well as established community groups and educational or religious leaders. The commissioners also ensure that local services have the skills mix and capacity to provide support that is culturally appropriate and tailored to the needs of people from black, Asian and other minority ethnic groups to make positive behaviour changes.
People from black, Asian and other minority ethnic groups advise on what local health and wellbeing programmes should focus on and what culturally sensitive and acceptable services should look like. They share their views during workshops or consultations organised by the commissioners, or through other people who they trust, such as community leaders or faith leaders.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. Commissioners and providers seeking to obtain the views and understand the needs of people from black, Asian and other minority ethnic groups should work closely with existing community groups, faith leaders and educators who may already have links to groups and individuals with poor access to services.

Peer and lay roles

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups are represented in peer and lay roles within local health and wellbeing programmes.

Rationale

People from black, Asian and other minority ethnic groups are underrepresented in health and wellbeing programmes. To ensure that the programmes are accessed and used by minority ethnic groups, commissioners and providers need to recognise the knowledge, skills and expertise of local communities. People known to and trusted by communities can take on peer and lay roles and encourage uptake of services among groups that may otherwise be reluctant to get involved. They can raise awareness, deliver information and advice in a culturally appropriate manner, and help with designing and providing interventions and services that are relevant, acceptable and tailored to the local population.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups are represented in peer and lay roles for local health and wellbeing programmes.
Data source: Local data collection, for example, from service planning and service design records, and recruitment records.
b) Evidence of local arrangements to support people from black, Asian and other minority ethnic groups taking on peer and lay roles in local health and wellbeing programmes.
Data source: Local data collection, for example, records of meetings, mentoring sessions, existing support networks or workshops with people taking on peer and lay roles.
Process
Proportion of local health and wellbeing programmes with people working in peer and lay roles who are representative of the local community.
Numerator – the number in the denominator with people working in peer and lay roles who are representative of the local community.
Denominator – the number of local health and wellbeing programmes.
Data source: Local data collection, for example, from service annual reports.
Outcome
a) The number of people from black, Asian and other minority groups who access local health and wellbeing programmes.
Data source: Local data collection, for example, review of service records.
b) The number of people in peer and lay roles supporting black, Asian and other minority ethnic groups to improve their health and wellbeing.
Data source: Local data collection, for example, review of service records.
c) Experience of engaging with local health and wellbeing programmes among people from black, Asian and other minority groups.
Data source: Local data collection, for example, service user survey.
d) Long-term retention of people in peer and lay roles.
Data source: Local data collection, for example, service annual report.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that they work with established community groups and educational or religious leaders to identify and recruit members of the local community who can support people from black, Asian and other minority ethnic groups and represent the diverse needs of the local population. They ensure that people in lay roles are supported with resources, information and mechanisms to proactively engage members of the community who may be excluded or disengaged. Service providers also support people in peer and lay roles with feedback, support networks, training and mentoring to allow them to fulfil their responsibilities, reach their full potential and continue with the role.
Commissioners (community and voluntary sector organisations and statutory services) understand the diversity of their local community and make a long-term commitment to funding and supporting effective community engagement approaches, such as peer and lay roles. They secure resources to recruit people to peer and lay roles and provide them with ongoing training and support.
People from black, Asian and other minority ethnic groups are given support and information by other members of their own community who are working closely with organisations that provide local health and wellbeing services. These people represent the interests and concerns of the community and ensure that local health and wellbeing programmes and services recognise the beliefs, expectations and values of people from black, Asian and other minority ethnic groups.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]
Peer and lay roles
Community members working in a non-professional capacity to support health and wellbeing initiatives. 'Lay' is the general term for a community member. 'Peer' describes a community member who shares similar life experiences to the community they are working with. Peer and lay roles may be paid or unpaid (that is, voluntary). Effective peer and lay approaches are:
  • Bridging roles to establish effective links between statutory, community and voluntary organisations and the local community and to determine which types of communication would most effectively help get people involved.
  • Carrying out 'peer interventions'. That is, training and supporting people to offer information and support to others, either from the same community or from similar backgrounds.
  • Community health champions who aim to reach marginalised or vulnerable groups and help them get involved.
  • Volunteer health roles whereby community members get involved in organising and delivering activities.
[NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. People in peer and lay roles may be more successful at engaging with and supporting people from similar backgrounds than traditional health and wellbeing services.

Referring people at high risk of type 2 diabetes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups at high risk of type 2 diabetes are referred to an intensive lifestyle change programme.

Rationale

People from certain ethnic communities have a higher risk of developing type 2 diabetes than those in the white European population. This includes people of South Asian, Chinese, black African and African-Caribbean family origin. In these populations, the risk of type 2 diabetes increases at an earlier age and at a lower BMI level. Many cases of type 2 diabetes are preventable through changes to a person's diet and physical activity levels. Evidence-based intensive lifestyle change programmes can significantly reduce the risk of developing type 2 diabetes for those at high risk.

Quality measures

Structure
Evidence of local arrangements for identifying and referring people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes.
Data source: Local data collection, for example, GP contracts.
Process
a) Proportion of people from black, Asian and other minority ethnic groups identified as being at high risk of type 2 diabetes who are referred to an intensive lifestyle change programme.
Numerator – the number in the denominator who are referred to an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are identified as being at high risk of type 2 diabetes.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).
b) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who attended the programme.
Numerator – the number in the denominator who attended an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
c) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who completed the programme.
Numerator – the number in the denominator who completed an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
Outcome
a) Change in BMI among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
b) Change in blood pressure among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
c) Change in HbA1c among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
d) Prevalence of type 2 diabetes among people from black, Asian and other minority groups.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and Public Health England’s Diabetes prevalence estimates for local populations.

What the quality statement means for different audiences

Service providers (such as GPs and community healthcare providers) ensure that people from black, Asian and other minority ethnic groups who are identified as being at high risk of developing type 2 diabetes are referred to an intensive lifestyle change programme. They also ensure that systems are in place to start diabetes prevention interventions at a lower BMI threshold in people from minority ethnic groups at increased risk of type 2 diabetes. This may involve people in peer and lay roles raising awareness, assessing risks and providing advice on diabetes prevention among those ethnic minorities.
Health and public health practitioners (such as GPs, practice nurses and community healthcare providers) are aware that some black, Asian and other minority ethnic groups have an increased risk of type 2 diabetes. They refer people who are at high risk to an intensive lifestyle change programme and provide advice to those with a lower level of risk.
Commissioners (clinical commissioning groups, NHS England and local authorities in sustainability and transformation partnership areas) ensure that intensive lifestyle change programmes are available for people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes. They work with ethnic minorities to ensure that programmes include a range of culturally sensitive and appropriate behaviour change interventions.
People from black, Asian and other minority ethnic group at high risk of type 2 diabetes are referred to culturally sensitive and appropriate services that can help them achieve healthy weight and be more active. Those who are not currently at high risk of type 2 diabetes are given information and further support relevant to their needs.

Source guidance

Definitions of terms used in this quality statement

Intensive lifestyle change programme
A structured and coordinated range of interventions provided in different venues for people identified as being at high risk of developing type 2 diabetes. It should be local, evidence-based and quality-assured. The aim is to help people to become more physically active and improve their diet. If the person is overweight or obese, the programme should result in weight loss. Programmes may be delivered to individuals or groups (or involve a mix of both) depending on the resources available. They can be provided by primary care teams and public, private or community organisations with expertise in dietary advice, weight management and physical activity.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
High risk of type 2 diabetes
High risk is defined as a fasting plasma glucose level of 5.5–6.9 mmol/litre or an HbA1c level of 42–47 mmol/mol (6.0–6.4%). These terms are used instead of specific numerical scores because risk assessment tools have different scoring systems. Examples of risk assessment tools include: Diabetes risk score assessment tool, QDiabetes risk calculator and Leicester practice risk score. Risk can also be assessed using the NHS Health Check.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
Lower thresholds (23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk) should be used for BMI to trigger action to prevent type 2 diabetes among Asian (South Asian and Chinese) populations compared to those used for the general population.

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may find it difficult to engage with services. Intensive lifestyle change programmes need to be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Cardiac rehabilitation

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are given a choice of times and settings for the sessions and are followed up if they do not attend.

Rationale

Cardiac rehabilitation programmes improve clinical outcomes for people who have had a cardiac event. However, uptake among people from black, Asian and other ethnic minority groups is lower than in the general population. Providing programmes that are culturally appropriate and sensitive, at settings and times that are convenient can increase uptake. Following up people who do not attend allows for a discussion about potential barriers to attendance and how to overcome them. It also gives the opportunity to motivate people to start or to continue with the programme.

Quality measures

Structure
a) Evidence of local arrangements to discuss any factors that might stop people from black, Asian or other minority ethnic groups from attending a cardiac rehabilitation programme, before they receive a referral.
Data source: Local data collection, for example, from service level agreements.
b) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups in a variety of settings including at home, in the community or in a hospital.
Data source: Local data collection, for example, from service level agreements.
c) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups at a choice of times, for example, sessions outside working hours.
Data source: Local data collection, for example, from service level agreements.
Process
a) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who are offered sessions in a variety of settings including home, the community or a hospital.
Numerator – the number in the denominator offered sessions in a variety of settings including home, the community or a hospital.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme.
Data source: Local data collection, for example, from patient records.
b) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme.
Data source: Local data collection, for example, from patient records.
c) Proportion of people from black, Asian and other minority ethnic groups who missed their cardiac rehabilitation appointment who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups participating in a cardiac rehabilitation programme who missed their appointment.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rate of uptake of cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
b) Rates of adherence to cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed cardiac rehabilitation programmes.
Data source: Local data collection, for example, surveys carried out with people referred to cardiac rehabilitation.

What the quality statement means for different audiences

Service providers (secondary and tertiary care services) ensure they provide individualised support for people from black, Asian and other minority ethnic groups to attend and continue with cardiac rehabilitation programmes. This may include working on overcoming barriers with people who are not willing to engage with services due to poor past experiences or ensuring that the programmes are run on different days, at different times and at venues that are culturally appropriate and convenient. Providers also ensure that a varied range of acceptable and culturally sensitive exercise is available, and people are followed up to continue with the programme.
Healthcare professionals (such as cardiologists and cardiac nurses) identify barriers to attending a cardiac rehabilitation programme and offer individualised support to people from black, Asian and other minority ethnic groups. They offer cardiac rehabilitation programmes on different days, at different times and venues (such as community centres or places of worship) and ensure that they are culturally appropriate and suitable. Healthcare professionals also follow-up people to motivate them to continue with the programme or understand the obstacles that may prevent people from using the service.
Commissioners (clinical commissioning groups) commission cardiac rehabilitation services that have the capacity and expertise to provide people from black, Asian and other minority ethnic groups with programmes that are suitable, acceptable and culturally appropriate. They also ensure that the services support people from black, Asian and other minority ethnic groups to attend and adhere to the programme by addressing the barriers to participation.
People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are supported to attend and keep going to the sessions. This might mean that sessions are available at venues and times convenient to the person or that the sessions are acceptable to them culturally, for example, single sex or with bilingual staff.

Source guidance

Definitions of terms used in this quality statement

Cardiac rehabilitation
A coordinated and structured programme designed to remove or reduce the underlying causes of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that people can, by their own efforts, continue to play a full part in their community and through improved health behaviour, slow or reverse progression of the disease. Cardiac rehabilitation should consist of a multidisciplinary, integrated approach delivering care in lifestyle risk factor management, psychosocial health, medical risk factor management and the optimal use of cardioprotective therapies, underpinned by psychologically informed methods of health behaviour change and education.
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components.
[NICE’s guideline on myocardial infarction, full guideline and recommendations 1.1.1 and 1.1.19]

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may find it difficult to engage with services. Also, some traditions and religious practices may stop people from accessing services on certain days or certain times of the day. Behaviour change programmes need to acknowledge those differences, be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Support for people with mental health problems

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups can access mental health services in a variety of community-based settings.

Rationale

People from black, Asian and other minority ethnic groups are less likely to access mental health treatment than the general population. Mental health illness can be associated with a considerable stigma among people from black, Asian and other minority ethnic groups. Some people may find community-based services, such as a person’s home or other residential settings, community centres and social centres, more appealing, accessible and culturally appropriate than traditional healthcare services. To help combat the stigma and encourage people with mental health problems to access support early, the services need to be visible, accessible and responsive to the needs of the local population.

Quality measures

Structure
a) Evidence of local arrangements to improve access to mental health services for people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, from local commissioning plans.
b) Evidence of local arrangements to ensure that mental health services are provided in a variety of settings that people from black, Asian and other minority ethnic groups can choose from.
Data source: Local data collection, for example, from service level agreements.
Process
Proportion of people from black, Asian and other minority ethnic groups accessing mental health services who are offered support in community-based settings.
Numerator – the number in the denominator offered support in community-based settings.
Denominator – the number of people from black, Asian and other minority ethnic groups accessing mental health services.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rates of uptake of mental health services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection for example, from GP records.
b) Proportion of people from black, Asian and other minority ethnic groups who complete treatment from mental health services.
Data source: Local data collection for example, from GP records.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed mental health services.
Data source: Local data collection, for example, surveys carried out with people referred to mental health services.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services, mental health services and independent providers) collaborate with local communities and people from black, Asian and other minority ethnic groups, healthcare professionals and commissioners to develop local care pathways that promote mental health services tailored to the needs of the local population. They ensure that services are provided in settings accessible and acceptable to people from black, Asian and other minority ethnic groups with mental health problems.
Healthcare professionals (such as GPs, psychiatrists, mental health nurses) offer people from black, Asian and other minority ethnic groups different options for where they can access mental health support to ensure they can choose acceptable and culturally appropriate services. They also collaborate with service providers, commissioners, communities and people from black, Asian and other minority ethnic groups to develop local care pathways that promote mental health services tailored to the needs of the local population.
Commissioners (such as clinical commissioning groups and local authorities) collaborate with local communities, people from black, Asian and other minority ethnic groups, healthcare professionals and service providers to develop local care pathways tailored to the needs of the local population. They ensure that mental health services are provided in a variety of settings and a range of support is available to facilitate access and uptake of services among people from black, Asian and other minority ethnic groups.
People from black, Asian and other minority ethnic groups are given a choice of places to access mental health support. Locations may include their own home, a community or social centre, a GP practice or other local health clinic.

Source guidance

Common mental health problems: identification and pathways to care (2011) NICE guideline CG123, recommendation 1.1.1.7

Definitions of terms used in this quality statement

Community-based settings
Community-based settings include the person's home or other residential settings, community centres and social centres.
[NICE’s guideline on common mental health problems, recommendation 1.1.1.7]

Equality and diversity considerations

Stigma attached to mental health problems among people from the black, Asian and other minority ethnic groups and fear of being sectioned or having children taken away by social services may stop people from accessing mental health support early. To ensure they are culturally appropriate and tailored to the diverse needs of the local population, members of the community should be involved in designing and reviewing the services as well as represented in peer and lay roles to ensure good links into the community.

Physical health checks for people with serious mental illness

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.

Rationale

Life expectancy for adults with a serious mental illness is significantly lower than for people in the general population. People from some black, Asian and other minority ethnic groups are at an increased risk of cardiovascular disease and type 2 diabetes and these conditions can be exacerbated by the use of antipsychotics. An annual health check helps to pick up on early signs of physical health conditions and enables action to be taken to prevent worsening health.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
b) Evidence of local primary and secondary care services working together to monitor and address the physical health needs of people affected by serious mental illness as part of the Rethink Mental Health Integrated Physical Health Pathway.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
Process
Proportion of people from black, Asian and other minority ethnic groups with a serious mental illness who have had a physical health assessment within the past 12 months.
Numerator – the number in the denominator who have had a physical health assessment within the past 12 months.
Denominator – the number of people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
Outcome
a) Premature mortality rates among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
b) Prevalence of type 2 diabetes among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).

What the quality statement means for different audiences

Service providers (such as GPs or mental health services) have systems in place to ensure that physical health assessments are carried out at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. The results are shared (under shared care arrangements) when the service user is in the care of both primary and secondary services. Service providers may involve people in peer and lay roles to support raising awareness of the increased risks and importance of physical health checks among people from black, Asian and other ethnic minority groups with a serious mental illness.
Healthcare professionals (such as GPs or nurses) carry out physical health assessments at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. They share the results (under shared care arrangements) when the service user is in the care of both primary and secondary services. They also highlight the increased risks and importance of physical health checks to people from black, Asian and other ethnic minority groups with a serious mental illness.
Commissioners (such as NHS England local area teams) ensure that they commission services that can demonstrate they are carrying out physical health assessments at least annually in people from black, Asian and other minority ethnic groups with a serious mental illness, and include this requirement in continuous training programmes. They also ensure that shared care arrangements are in place when the service user is in the care of both primary and secondary services, to ensure that the results of assessments are shared.
People from black, Asian and other minority ethnic groups with serious mental health problems have regular health checks (at least once a year). This is to check for problems that are common in people being treated for a serious mental illness, such as weight gain, diabetes, and heart, lung and breathing problems. The results are shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Serious mental illness
Schizophrenia, bipolar affective disorder and other psychoses.
Physical health assessment
A comprehensive health check focused on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease. The annual check should include:
  • weight or BMI, diet, nutritional status and level of physical activity
  • cardiovascular status, including pulse and blood pressure
  • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
  • liver function
  • renal and thyroid function, and calcium levels, for people taking long-term lithium.
[Adapted from NICE’s guideline on bipolar disorder, recommendations 1.2.11 and 1.2.12]

Advice for adults during NHS Health Checks

This quality statement is taken from the physical activity: for NHS staff, patients and carers quality standard. The quality standard defines clinical best practice in physical activity: encouraging activity in all people in contact with the NHS and should be read in full.

Quality statement

Adults having their NHS Health Check are given brief advice about how to be more physically active.

Rationale

The primary care setting provides opportunities to implement the principles of the Making Every Contact Count initiative by enabling healthcare professionals to deliver lifestyle advice as a preventative measure. The NHS Health Check aims to reduce the risk of a number of conditions that physical activity can help to prevent. The NHS Health Check gives healthcare professionals a good opportunity to give brief advice to adults on a one‑to‑one basis about the benefits of physical activity and of using local physical activity services such as walking groups. This should therefore lead to an increase in physical activity levels.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are having their NHS Health Check are given brief advice about how to be more physically active.
Data source: Local data collection. NHS Health Check Data Set – NHS Health Check: Coverage.
Process
a) Proportion of adults having their NHS Health Check whose records state that they have been given brief advice about how to be more physically active.
Numerator – the number in the denominator whose records state that they have been given brief advice about how to be more physically active as part of their NHS Health Check.
Denominator – the number of adults having their NHS Health Check.
Data source: Local data collection. NHS Health Check Data Set – NHS Health Check: Referrals and risk management.
b) Proportion of adults having their NHS Health Check who are identified as needing to do more physical activity after receiving brief advice and whose records state that they have been signposted to physical activity services.
Numerator – the number in the denominator whose records state that they have been signposted to physical activity services as part of their NHS Health Check.
Denominator – the number of adults having their NHS Health Check who are identified as needing to do more physical activity after receiving brief advice.
Data source: Local data collection. NHS Health Check Data Set – NHS Health Check: Referrals and risk management.
c) Proportion of adults who have had an NHS Health Check and been signposted to physical activity services whose outcome is recorded.
Numerator – the number in the denominator whose outcome is recorded.
Denominator – the number of adults who have had their NHS Health Check and been signposted to physical activity services.
Data source: Local data collection. NHS Health Check programme standards – section 7 on risk management.
Outcome
Proportion of adults meeting the recommendations in the UK physical activity guidelines.
Data source: Contained within the Health and Social Care Information Centre's Health Survey for England: Health, social care and lifestyles, chapter on physical activity in adults and Sport England's Active People Survey.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services such as GP surgeries and pharmacies) ensure that their staff are trained and competent to give adults who are having their NHS Health Check brief advice about how to be more physically active, and in signposting adults to physical activity services.
Healthcare professionals (such as GPs and pharmacists) give adults who are having their NHS Health Check brief advice about how to be more physically active, and signpost them to physical activity services.
Commissioners (NHS England and local authorities) ensure that they commission services in which NHS Health Checks include giving brief advice to adults about physical activity, and signposting them to physical activity services.

What the quality statement means for patients, service users and carers

Adults having their NHS Health Check are given advice and information about how to be more physically active and what services are available locally. The NHS Health Check is a national programme to identify people at risk of heart disease, stroke, diabetes, kidney disease and certain types of dementia.

Source guidance

Definitions of terms used in this quality statement

Brief advice
Giving brief advice or intervention involves oral discussion, negotiation or encouragement, with or without written or other support or follow‑up. It may also involve a referral for further interventions, directing people to other services or more intensive support. In this context, if the person is already achieving the UK physical activity guidelines the advice should focus on sustaining this by offering praise and encouragement. Brief advice can be delivered by anyone who is trained in the necessary skills and knowledge. These interventions typically take no more than a few minutes for basic advice. [Adapted from Physical activity: brief advice for adults in primary care (NICE guideline PH44), Behaviour change: individual approaches (NICE guideline PH49), and expert opinion]
NHS Health Check
The NHS Health Check programme aims to help prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia. Everyone between the ages of 40 and 74, who have not already been diagnosed with 1 of these conditions will be invited (once every 5 years) to have a check to assess their risk of heart disease, stroke, kidney disease and diabetes. People attending NHS Health Checks will have their risk assessed through a combination of their personal details, family history of illness, smoking, alcohol consumption, physical activity, BMI, blood pressure and cholesterol. They should be given support and advice to help them reduce or manage their risk. [Adapted from NHS Health Check competence framework (Public Health England) and NICE local government briefing 15]
Signposting to physical activity services
Signposting describes the process for directing a person to a suitable local service. As part of an NHS Health Check, a person may be signposted or directed to the local gym or walking group, for example, or referred to lifestyle or clinical services. This aims to help guide people to local services that are appropriate for them. This will encourage people to use the services and support them in making lifestyle changes. [Adapted from NHS Health Check Data Set user guidance (Health and Social Care Information Centre)]
UK physical activity guidelines
The current recommendations for physical activity from the Chief Medical Office state the following:
  • All adults aged 19 years and over should aim to be active daily.
  • Over a week, this should add up to at least 150 minutes (2.5 hours) of moderate intensity physical activity in bouts of 10 minutes or more.
  • Alternatively, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or combinations of moderate and vigorous intensity activity.
  • All adults should also undertake physical activity to improve muscle strength on at least 2 days a week.
  • They should minimise the amount of time spent being sedentary for extended periods.
  • Older adults (65 years and over) who are at risk of falls should incorporate physical activity to improve balance and coordination on at least 2 days a week.
  • Individual physical and mental capabilities should be considered when interpreting the guidelines, but the key issue is that some activity is better than no activity. [UK physical activity guidelines (Department of Health)]

Equality and diversity considerations

When advising adults to become more physically active and signposting them to physical activity services, healthcare professionals should take into account gender, the needs of people from different socioeconomic backgrounds and cultures, and the needs of adults with mental health conditions and learning or physical disabilities. When providing written information, healthcare professionals should ensure that it is accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English.

Advice for parents or carers as part of the Healthy Child Programme 2-year review

This quality statement is taken from the physical activity: for NHS staff, patients and carers quality standard. The quality standard defines clinical best practice in physical activity: encouraging activity in all people in contact with the NHS and should be read in full.

Quality statement

Parents or carers of children are given advice about physical activity during their child's Healthy Child Programme 2‑year review.

Rationale

Children's participation in physical activity is important for their healthy growth and development. It is important to establish being physically active as a life‑long habit from an early age, and the Healthy Child Programme 2‑year review provides a good opportunity to advise on this. Giving advice to parents and carers at key points during their child's development can be an effective way to 'make every contact count'. It can also lead to whole families establishing good physical activity habits.

Quality measures

Structure
Evidence of local arrangements to ensure that parents or carers of children are given advice about physical activity as part of their child's Healthy Child Programme 2‑year review.
Data source: Local data collection.
Process
a) Proportion of Healthy Child Programme 2‑year reviews in which parents or carers of children are given advice about physical activity.
Numerator – the number in the denominator in which parents or carers of children are given advice about physical activity.
Denominator – the number of Healthy Child Programme 2‑year reviews.
b) Proportion of Healthy Child Programme 2‑year reviews in which parents or carers of children are offered written information about local opportunities to be physically active.
Numerator – the number in the denominator in which parents or carers of children are offered written information about local opportunities to be physically active.
Denominator – the number of Healthy Child Programme 2‑year reviews.
Data source: Local data collection.
Outcome
Proportion of children achieving the recommendations in the UK physical activity guidelines.
Data source: Contained within the Health and Social Care Information Centre's Health Survey for England: Health, social care and lifestyles, chapter on physical activity in children.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (health visiting services) ensure that their staff are trained to give parents or carers of children advice about physical activity and information about local opportunities to be physically active as a key component of the Healthy Child Programme 2‑year review.
Healthcare professionals (health visitors, nursery nurses and children's nurses) give parents or carers advice about physical activity and information about local opportunities to be physically active as a key component of the Healthy Child Programme 2‑year review.
Commissioners (such as clinical commissioning groups, NHS England and local authorities) ensure that they commission services from providers who include giving advice about physical activity and information about local opportunities as a key component of the Healthy Child Programme 2‑year review. Commissioners may wish to monitor activity by requesting evidence of practice locally.

What the quality statement means for patients, service users and carers

Parents or carers of children who are having their 2-year review are given information about the ways in which their child can benefit from being physically active. They are also given information about what they can do to be more active, as well as what is available locally.

Source guidance

Definitions of terms used in this quality statement

Advice about physical activity as part of the Healthy Child Programme 2-year review
Parents and carers of children should be advised that:
  • Children of pre‑school age who are capable of walking unaided should be physically active daily for at least 180 minutes (3 hours), spread throughout the day.
  • All children should undertake a range of moderate to vigorous intensity activities for at least 60 minutes over the course of a day.
  • All children should minimise the amount of time they spend being sedentary (being restrained or sitting) for extended periods (except time spent sleeping).
  • It is beneficial for them to get involved in physical activities with their children and to complete at least some local journeys (or some part of a local journey) with young children using a physically active mode of travel with the aim of establishing active travel as a life‑long habit from an early age.
Parents and carers of children should be given oral and written information about:
Healthy Child Programme 2-year review
This is the third, full health and development review that children have as part of the Healthy Child Programme. This review will be carried out between the age of 2 and 2.5 years by a member of the Healthy Child team, usually a health visitor, nursery nurse or children's nurse. The review might be at a local children's centre, GP surgery or at home. [Adapted from NHS Choices, The Healthy Child Programme]

Equality and diversity considerations

When giving parents and carers advice on physical activity for children, healthcare professionals should take into account the age, developmental stage and gender of the child, any medical needs as well as the ethnicity and socioeconomic status of the family in order to communicate the information in a sensitive manner. All information given about physical activity should be accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English.
When sharing information about local opportunities to be active, healthcare professionals should take into account the needs of children from different socioeconomic backgrounds, and the needs of children with mental health conditions, and learning and physical disabilities.

Advice for parents or carers as part of the National Child Measurement Programme

This quality statement is taken from the physical activity: for NHS staff, patients and carers quality standard. The quality standard defines clinical best practice in encouraging activity in all people in contact with the NHS and should be read in full.

Quality statement

Parents or carers of children are given advice about physical activity as part of the National Child Measurement Programme (NCMP).

Rationale

Children's participation in physical activity is important for their healthy growth and development. It is important to establish being physically active as a life‑long habit from an early age. Giving advice to parents and carers at key points during their child's development can be an effective way to 'make every contact count'. It can also lead to whole families establishing good physical activity habits.
The NCMP is delivered by all local authorities across England and involves measuring the weight and height of children aged 4 to 5 years and 10 to 11 years to assess overweight children and obesity levels in primary schools. Parents or carers receive feedback about their children's results. While it is not a mandated component of the programme, local authorities are encouraged to provide parents with their child's results. The National Child Measurement Programme Operational Guidance additionally highlights that parents generally want to receive their child's NCMP results, and that providing this information is an effective mechanism for raising awareness of the potential associated health consequences of excess weight. This therefore provides a good opportunity to give advice about physical activity, because parents are more likely to be receptive to thinking about behaviour change.

Quality measures

Structure
Evidence of local arrangements to ensure that parents or carers of children are given advice about physical activity as part of the NCMP.
Data source: Local data collection.

Process

a) Proportion of children aged 4 to 5 years who are measured as part of the NCMP whose parents or carers are given advice about physical activity.
Numerator – the number in the denominator whose parents or carers are given advice about physical activity.
Denominator – the number of children aged 4 to 5 years who are measured as part of the NCMP.
Data source: Local data collection.
b) Proportion of children aged 10 to 11 years who are measured as part of the NCMP whose parents or carers are given advice about physical activity.
Numerator – the number in the denominator whose parents or carers are given advice about physical activity.
Denominator – the number of children aged 10 to 11 years who are measured as part of the NCMP.
Data source: Local data collection.
Outcome
Proportion of children achieving the recommendations in the UK physical activity guidelines.
Data source: Contained within the Health and Social Care Information Centre's Health Survey for England: Health, social care and lifestyles, chapter on physical activity in children.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (such as school nursing services) ensure that their staff are trained to give parents or carers of children advice about physical activity and information about local opportunities to be physically active as a key component of the routine feedback that is provided to parents or carers of children who are measured as part of the NCMP.
Healthcare practitioners incorporate advice about physical activity within the routine feedback they provide to parents or carers of children who are measured as part of the NCMP.
Commissioners (Public Health England, NHS England and local authorities) ensure that they commission services from providers who include giving advice about physical activity as a key component of the routine feedback they provide to parents or carers of children who are measured as part of the NCMP. Commissioners may wish to monitor activity by requesting evidence of practice locally.

What the quality statement means for patients, service users and carers

Parents or carers of children whose weight and height is measured at school as part of the National Child Measurement Programme are given information about the ways in which their child can benefit from being physically active. They are also given information about what they can do to be more active, as well as what is available locally. The National Child Measurement Programme was established in 2005, and involves measuring the weight and height of Reception and Year 6 children at state schools in England.

Source guidance

Definitions of terms used in this quality statement

Advice about physical activity as part of the National Child Measurement Programme
Parents and carers of children should be given written information advising them that:
  • All children should undertake a range of moderate to vigorous intensity activities for at least 60 minutes over the course of a day.
  • Children aged 5 years and over should undertake vigorous intensity activities, including those that strengthen muscle and bone, at least 3 days a week.
  • All children should minimise the amount of time they spend being sedentary (being restrained or sitting) for extended periods (except time spent sleeping).
  • It is beneficial for them to get involved in physical activities with their children and to complete at least some local journeys (or some part of a local journey) with young children using a physically active mode of travel with the aim of establishing active travel as a life‑long habit from an early age.
Parents and carers of children should also be given written information about:
  • The benefits of physical activity and how enjoyable it is.
  • Local opportunities to be physically active.
The National Child Measurement Programme Operational Guidance includes specimen result letters to parents that can be adapted to include advice about physical activity for all children who take part in the programme. [Adapted from UK physical activity guidelines (Department of Health), Promoting physical activity for children and young people (NICE guideline PH17) recommendation 15, and expert opinion]
National Child Measurement Programme (NCMP)
The NCMP was established in 2005, and involves measuring the weight and height of Reception and Year 6 children at state‑maintained schools, including academies, in England.
The NCMP has 2 key purposes:
  • To provide robust public health surveillance data on child weight status: to understand and monitor obesity prevalence and trends at national and local levels, inform obesity planning and commissioning, and underpin the Public Health Outcomes Framework indicators on excess weight in children aged 4–5 years and 10–11 years.
  • To provide parents with feedback on their child's weight status: to help them understand their child's health status, support and encourage behaviour change, and provide a mechanism for direct engagement with families. [Adapted from National Child Measurement Programme Operational Guidance, Public Health England]

Equality and diversity considerations

When giving parents and carers advice on physical activity for children, healthcare professionals should take into account the age and gender of the child, as well as the ethnicity and socioeconomic status of the family in order to communicate the information in a sensitive manner. All information given about physical activity should be accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English.
When sharing information about local opportunities to be active, healthcare professionals should take into account the needs of children from different socioeconomic backgrounds, and the needs of children with mental health conditions, and learning and physical disabilities.

Implementing a physical activity programme for employees in NHS organisations

This quality statement is taken from the physical activity: for NHS staff, patients and carers quality standard. The quality standard defines clinical best practice in encouraging activity in all people in contact with the NHS and should be read in full.

Quality statement

NHS organisations have an organisation-wide, multi-component programme to encourage and support employees to be more physically active.

Rationale

Multi-component physical activity programmes in NHS organisations should incorporate a range of measures to encourage and support their employees to be more physically active. Providing information about physical activity and promoting its health benefits should help support people who are interested in becoming more active. Identifying an 'active travel champion' (working at a senior level) to promote active travel should increase the number of NHS employees who adopt more active modes of travel for commuting and while at work. This should encourage and enable employees to increase the amount of physical activity they undertake and improve their overall health and wellbeing.

Quality measures

Structure
a) Evidence that NHS organisations have in place an organisation wide, multi component programme to encourage and support employees to be more physically active.
Data source: Local data collection.
b) Evidence that NHS organisations monitor their organisation wide, multi component physical activity programme.
Data source: Local data collection. Contained within the Royal College of Physicians' Implementing NICE public health guidance for the workplace – organisational audit, section 3.3: Physical activity and building/site design.
c) Evidence that NHS organisations encourage active travel through schemes that have been developed or promoted by an active travel champion.
Data source: Local data collection.
Process
a) Proportion of NHS organisations with a multi component physical activity programme that disseminate information (including written information) on at least an annual basis to their employees on how to be more physically active and on the health benefits of such activity.
Numerator – the number in the denominator that disseminate information (including written information) on at least an annual basis on how to be more physically active and on the health benefits of such activity to their employees.
Denominator – the number of NHS organisations with a multi component physical activity programme.
Data source: Local data collection.
b) Proportion of organisation-wide, multi-component physical activity programmes in NHS organisations that include incentive schemes.
Numerator – the number in the denominator that include incentive schemes.
Denominator – the number of organisation-wide, multi component physical activity programmes in NHS organisations.
Data source: Local data collection.
c) Proportion of employees in NHS organisations who take part in incentive schemes that are part of a multi component physical activity programme.
Numerator – the number in the denominator who take part in incentive schemes that are part of a multi component physical activity programme.
Denominator – the number of people employed by an NHS organisation that has incentive schemes included within a multi component physical activity programme.
Data source: Local data collection.
d) Proportion of NHS employees recorded as having taken part in active travel schemes that are led or promoted by their organisation within the last 12 months.
Numerator – the number in the denominator recorded as having taken part in active travel schemes that are led or promoted by their organisation within the last 12 months.
Denominator – the number of people employed by an NHS organisation with active travel schemes.
Data source: Local data collection.

Outcomes

a) Proportion of employees in NHS organisations who feel supported to be more physically active.
Data source: Local data collection. The NHS staff survey (2014) contained the following questions: 14b My immediate manager takes a positive interest in my health and wellbeing; 14c My organisation takes positive action on health and wellbeing.
b) Proportion of NHS employees who use physically active modes of travel for commuting and while at work.
Data source: Local data collection. The National Travel Survey for England (2013) contains information on: Commuting/business trips by main mode (chart 15). The 2011 UK Census data contains information on: Method of travel to work for England and Wales.

What the quality statement means for NHS organisations

NHS organisations have an organisation-wide, multi-component programme to encourage and support employees to be more physically active, and monitor the uptake of the programme initiatives and incentive schemes by employees.
Active travel champions ensure that they coordinate activities, and develop or promote schemes that encourage and enable employees in their organisation to use active modes of travel, such as walking and cycling.

What the quality statement means for employees in NHS organisations

Employees in NHS organisations are encouraged and supported to be more physically active (both within and outside the workplace), and are provided with information and practical support on how to do this.

Source guidance

Definitions of terms used in this quality statement

Employees in NHS organisations
In this context, employees include people who are employed directly by any type of NHS organisation. Where possible, this would also include people who are employed by any type of an NHS organisation through a subcontract, as a volunteer or as a temporary member of staff. [Adapted from Promoting physical activity in the workplace (NICE guideline PH13)]
Multi-component programme
The programme should consist of a number of components in order to ensure that employees with different needs and interests are encouraged and supported to be more physically active. It should be linked to and support achievement of the goals outlined in the organisation wide policy or plan for physical activity. It could include:
  • Incentive schemes such as Cycle to Work schemes and subsidised gym memberships.
  • Mechanisms to support employees to walk, cycle or use other modes of transport involving physical activity (to travel to and from work and as part of their working day). Examples of mechanisms include:
    • providing facilities such as bicycle storage, showers and changing facilities
    • ensuring that staircases are clearly signposted and attractive to use, to encourage people to use the stairs rather than lifts if they can
    • offering flexibility around taking breaks to enable employees to take short walks during work breaks
    • developing (or promoting) schemes that facilitate active travel, for example, schemes that give staff access to a pool of bicycles for short distance business travel, or access to discounted cycle purchases (such as Cycle to Work schemes).
  • Providing information (including written information) on how to minimise sedentary behaviour and be more physically active, and on the health benefits of such activity.
  • Written information on local opportunities to be physically active (both within and outside the workplace) tailored to meet specific needs, for example, the needs of shift workers. Examples include information about: walking and cycling routes (this may include maps), local walking groups, exercise classes, cycle training programmes and local challenges and events.
  • Ongoing advice and support to help people plan how they are going to increase their levels of physical activity and reduce sedentary behaviour. This may include a confidential, independent health check administered by a suitably qualified practitioner and focused on physical activity.
To deliver the programme, employers could:
  • Ensure that when planning new developments and refurbishing existing buildings, they maximise opportunities for people (including those who have limited mobility) to be physically active as a routine part of their daily life. As part of the planning, employers should:
    • Involve local communities and experts to ensure the potential for physical activity is maximised.
    • Complete an assessment in advance, of the impact (both intended and unintended) that the proposals are likely to have on physical activity levels. Results should be made publicly available and accessible.
  • Help employees to be physically active and minimise sedentary behaviour during the working day by:
    • where possible, encouraging them to move around more at work (for example, by walking or cycling to external meetings or standing up during meetings)
    • encouraging them to set goals on how far they walk and cycle and to monitor the distances they cover.
  • Take account of the nature of the work and any health and safety issues. For example, many people already walk long distances during the working day, whereas those involved in shift work may be vulnerable if walking home alone at night.
  • Work in collaboration with other NHS organisations. This is particularly relevant for smaller organisations that may find it challenging to deliver activities in isolation. [Adapted from Promoting physical activity in the workplace (NICE guideline PH13) recommendations 2 and 3, Physical activity and the environment (NICE guideline PH8) recommendations 1, 5 and 6, Walking and cycling: local measures to promote walking and cycling as forms of travel or recreation (NICE guideline PH41) and expert consensus]
Active travel champion
Active travel champions working in NHS organisations should be enthusiastic and passionate about physical activity, and able to engage with and support people to become more active. They should have the ability to influence people working at a senior level, and should encourage and enable employees to be more physically active.

Equality and diversity considerations

When developing an organisation-wide, multi-component physical activity programme, NHS employers should take into account the needs of employees with mental health conditions, and learning and physical disabilities. Any written information provided as part of the programme should be accessible to people with additional needs, such as physical, sensory or learning disabilities.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Behaviour change principles: highlights

  • Carefully plan interventions and programmes aimed at changing behaviour, taking into account the local and national context and working in partnership with recipients. Interventions and programmes should be based on a sound knowledge of community needs and should build upon the existing skills and resources within a community.
  • Equip practitioners with the necessary competencies and skills to support behaviour change, using evidence-based tools. (Education providers should ensure courses for practitioners are based on theoretically informed, evidence-based best practice.)
  • Evaluate all behaviour change interventions and programmes, either locally or as part of a larger project. Wherever possible, evaluation should include an economic component.

Definitions

Behaviour change interventions

Behaviour change interventions involve sets of techniques, used together, which aim to change the health behaviours of individuals, communities or whole populations.

Behaviour change programmes

Multi-agency, multi-packages and/or a series of related policies, services and interventions or other actions focused on broad strategic issues. Programmes can involve a suite of activities that may be topic, setting or population-based – and may involve changes to organisational infrastructures.

Behaviour change practitioners

Anyone who delivers behaviour change techniques and interventions can be a behaviour change practitioner, regardless of their professional background, as long as they have received specific training in these techniques. However, not all practitioners can deliver all interventions or techniques.

Behaviour change techniques

The term 'behaviour change technique' is used in these recommendations to mean the component of an intervention that has been designed to change behaviour, such as social support. The technique must meet specified criteria so that it can be identified, delivered and reliably replicated. It should also be observable and irreducible (behaviour change techniques are the smallest 'active' component of an intervention.) They can be used alone or in combination with other behaviour change techniques.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Equality Act 2010

The recommendations should be implemented in light of duties set out in the Equality Act 2010.

Supporting information

Glossary

the skills, talents and capacity that individuals, associations and organisations can share to improve the life of a community. An assets approach focuses on the strengths rather than the weaknesses (or deficiencies) found in groups or communities
describe the knowledge and skills required to deliver interventions to people to help them change their behaviour (Dixon and Johnston 2010)
involves oral discussion, negotiation or encouragement, with or without written or other support or follow-up. It may also involve a referral for further interventions, directing people to other options, or more intensive support. Brief interventions can be delivered by anyone who is trained in the necessary skills and knowledge. These interventions are often carried out when the opportunity arises, typically taking no more than a few minutes for basic advice
for any change in behaviour to occur, a person must: be physically and psychologically capable of performing the necessary actions; have the physical and social opportunity (people may face barriers to change because of their income, ethnicity, social position or other factors; for example, it is more difficult to have a healthy diet in an area with many fast food outlets, no shops selling fresh food and with poor public transport links if you do not have a car); be more motivated to adopt the new, rather than the old behaviour, whenever necessary. This is known as the COM-B model (Michie et al. 2011d)
ensure public services are developed and delivered by professionals, people using the services, their families and their neighbours working together in an equal and reciprocal way to agree what is needed, where and how
social or family group linked by networks, geographical location or another common factor
social or family groups linked by networks, geographical location or another common factor
similar in content to a brief intervention but usually lasts more than 30 minutes and consists of an individually-focused discussion. It can involve a single session or multiple brief sessions
similar in content to brief interventions but usually last more than 30 minutes and consist of an individually-focused discussion. They can involve a single session or multiple brief sessions
a specific behaviour (for example, alcoholic drinks consumed) or outcome (for example, changes in weight following changes to diet) is recorded. The person trying to change their behaviour is given feedback on the recorded behaviour or outcomes (for example, measurement of weight) or comment on progress towards a set goal. Monitoring can be done by a third party, or by the person themselves ('self-monitoring')
a group of behaviour change techniques that help people to set goals for their behaviour or for an outcome of the behaviour (such as weight loss) and plan how these goals will be met. Action plans include a description of what will happen in what situation or at what time; how often it will happen, for how long; and where it will take place. Behaviour goals are reviewed regularly in the light of experience and further plans are made according to past progress towards goals
conducted by someone who is not involved in commissioning or delivering an intervention and does not have a vested interest in the outcome. Evaluations can look at process or outcome and answer such questions as: was an intervention delivered according to the plan or service specification? what changes were there in the behaviour of, or health outcomes for, service users? why did the planned intervention lead (or not lead) to changes in behaviour or health outcomes?
action that aims to help someone with a specific health condition, or a behaviour that may affect their health. It can be delivered on a one-to-one, group or remote basis, but the focus is on creating measurable change in a specific person. A nutritional intervention offered to anyone with a specific biomarker (for example, a specific body mass index) or health status (for example, obesity) is an example. However, a nutritional intervention offered to everyone in the country, or a particular city, is not. Although delivered to an individual, the intervention may affect a whole group or population. The interventions referred to throughout the guidance include one or more behaviour change technique
intervention fidelity is the degree to which the planned components of an intervention have been delivered as intended
a narrative or visual depiction of real-life processes leading to a desired result. Using a logic model as a planning tool allows precise communication about the purposes of a project or intervention, its components and the sequence of activities needed to achieve a given goal. It also helps to set out the evaluation priorities right from the beginning of the process
the process that starts, guides and maintains goal-related behaviour, for example making changes to diet and exercise to lose weight. It involves biological, emotional, social and cognitive forces
Includes, Health Education England, Public Health England, Local Government Association, NHS England, Department of Health, Office of National statistics, and national organisations responsible for research funding
the impact that a test, treatment, policy, programme or other intervention has on a person, group or population. Outcomes from interventions to improve the public's health could include changes in their knowledge and behaviour leading to a change in their health and wellbeing
the aggregate of individuals defined by membership of a social, geographic, political or economic unit (for example, members of a state, a region, a city or a cultural group)
the aggregate of individuals defined by membership of a social, geographic, political or economic unit (for example, members of a state, a region, a city or a cultural group)
population-level interventions are national policies or campaigns that address the underlying social, economic and environmental conditions of a population to improve everyone's health. This type of intervention could include, for example, distributing leaflets to the whole population highlighting the importance of being physically active, adopting a healthy diet and being a healthy weight
in a proportionate universalist approach, interventions are delivered to the whole population, with the intensity adjusted according to the needs of specific groups (for example, some groups may need more frequent help and advice). This type of approach can help to reduce the social gradient and benefit everybody
the ability to withstand or even respond positively to stressors, crises or difficulties
involves friends, relatives, or colleagues providing support for people who want to change their behaviour (for example, to quit smoking). It can take the form of: practical help (for example, helping someone to free up the time they need to get to a service or use a facility, or helping them to get there); emotional support (for example, a partner or friend could go walking or cycling with the person on a regular basis if they want to get physically fit); praise or reward for trying to change, whatever the result. (For example, a partner or friend could make sure they congratulate the person for attempting to lose weight or stop smoking.)
a system of naming, describing and classifying techniques, items or objects. For example, a website taxonomy includes all the elements of a website and divides them into mutually exclusive groups and subgroups. An example of a behaviour-change technique taxonomy that can be applied across behaviours is described in Michie et al. 2013Michie S, Richardson M, Johnston M et al. (2013) The behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behaviour change interventions. Annals of behavioural medicine March 20 [Epub ahead of print].
a very brief intervention can take from 30 seconds to a couple of minutes. It is mainly about giving people information, or directing them where to go for further help. It may also include other activities such as raising awareness of risks, or providing encouragement and support for change. It follows an 'ask, advise, assist' structure. For example, very brief advice on smoking would involve recording the person's smoking status and advising them that stop smoking services offer effective help to quit. Then, depending on the person's response, they may be directed to these services for additional support

Paths in this pathway

Pathway created: January 2014 Last updated: May 2018

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