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Interview: Sir Muir Gray
The public health specialist and author of Sod Sitting and The Walking Cure speaks to Kate Cracknell about diverting £100m of NHS funding from drugs to physical activity, and his plan to get GPs prescribing wellness
Healthcare is what you do for yourself, not what we do for you. We’ll try and deliver professional services to you, but self-care is the most important form of care.” This is the message Sir Muir Gray, the eminent public health doctor, would like to impart to the public.
That’s not to say Gray believes in pushing the full burden of healthcare squarely onto the individual. Quite the opposite: he’s very vocal in pushing for the medical community to engage much more with the preventative healthcare agenda. But he does believe individuals can do a lot to improve their own health, and being active lies at the very heart of his philosophy. The role for medical community is in disseminating this message.
He explains: “The very important message is this: up until now, we’ve been giving healthy people information about exercise and giving people diagnosed with a condition pills. However, if your mum is diagnosed with Type 2 diabetes, she needs advice about exercise even more than people who don’t have Type 2 diabetes. And that’s a big shift in people’s thinking.”
£100m for prevention
He continues: “Being active has been neglected for the last 40 years. All the talk has been of healthy eating, while stress and sitting have been ignored. I’ve been promoting activity for 45 years, but only recently has this become a popular and accepted message.”
But an accepted message it now is, as Gray explains: “As Simon Stevens [CEO of NHS England] made very clear in the organisation’s Five Year Forward View – published in 2014 – prevention will be one of the essential things to save the NHS.
“What I’m therefore proposing is that we shift £100m out of the NHS drug budget and into an activity budget – putting £100m of additional funding into prevention.
I expect to have a decision in principle this year.”
So what exactly will he do with that £100m? Gray explains: “It would be used at a local level, for community development. We’d take people – personal trainers, but also local voluntary groups who are already doing this sort of thing – out into the community to run activity initiatives. A number of football and rugby clubs are already doing this; what you need is someone with the right personality who can be a leader in getting people moving.
“This is where health clubs and gyms could get involved. There’s no ‘maybe’ about it: we should be getting trainers into bridge clubs, bingo halls, old people’s clubs, lunch clubs – the places where older people are already meeting. Because that’s my core focus: healthy ageing.
“We also need to look at how we can reach these people at home, through the internet or television. I’d like to see a digital TV channel offering a twice-a-day music and movement programme, for example – say at 11.00 o’clock and 4.00 o’clock – which gets people to stand up and get moving. We’re currently discussing that with Age UK.”
The nine-second prescription
Gray is also keen to get GPs on-board with exercise-based preventative healthcare. “These things take time, but the first thing we need to do is get GPs moving themselves. The average GP now walks fewer than 1,500 steps a day. I’m very keen to do something to help change that. If they would just get out at lunchtime for 10 minutes – that’s all I’m asking for to start off with. Not 10,000 steps or even 30 minutes, but 10 minutes.
“In fact, my key message to GPs is this: look after yourselves. You’re leading a very tough life with a busy working day, and we need you, so please look after yourselves. And please start by walking more.
“My second message to them is this: we need your support in encouraging everyone who has a long-term condition to be physically active.”
So how does he propose this might happen? After all, we already have a number of activity champions among UK GPs – the likes of Dr John Morgan, heralded in the national media as “the GP who prescribes walking” (see HCM NovDec 14, p42), and Dr Zoe Williams, physical activity and lifestyle ambassador for the Royal College of General Practitioners (see HCM Oct 16, p58) – but the momentum has still not swung this way across the board.
Neither are patients fully receptive to the preventative message, as Dr Chris van Tulleken discovered in his BBC documentary, The Doctor Who Gave Up Drugs (see p10), which van Tulleken has described as “a titanic failure”.
Gray acknowledges: “We won’t be able to reproduce the enthusiasts – the GPs who are already wholeheartedly embracing exercise and talking about it with all their patients – so the key is to keep it really simple. Our idea is for a nine-second wellness prescription. We know appointment times are short, so we just need GPs to give us nine seconds to say, ‘Oh, and by the way, we’re going to send you something really, really important called a wellness prescription’.
“This would be automatically emailed or sent to patients’ mobile phones after their GP appointment, so they get their drugs prescription, but they also get their wellness activity prescription. Then, every time they go to the pharmacy, the pharmacist and the assistant pharmacist would reinforce that message. In this way we can get it right into mainstream clinical practice.
“Obviously we can all think of someone who doesn’t have an email – but I can think of 40 million people who do.”
Walking Plus
He continues: “GPs won’t have time to tailor the prescription, but that doesn’t matter because the message is essentially the same for Type 2 diabetes, heart failure, being 70…
“The prescription would be for what I call ‘Walking Plus’. You’ll feel better, you’ll reduce your risk of disability, and the treatment of your disease will be improved if you do 10 minutes’ walking a day – preferably building up to 3 x 10 – but also remember to do 10 minutes of stretching and resistance exercises to maintain your core and upper body strength. That will help you if you’re aged 40–60: it will help you with repetitive strain injury and back ache. If you’re over 60, it will help you stay out of an old people’s home.”
It’s often said that GPs don’t embrace ‘exercise as medicine’ due to a lack of training in physical activity, but Gray dismisses this: “GPs don’t know what’s inside the pills they prescribe – they don’t know the chemicals – so they don’t need detailed knowledge of fitness either. They just need encouragement.
“The key problem for GPs is time, so we have to be realistic in what we ask them for. I’ve gone for nine seconds.”
Sod Sitting!
And what about those aged under 40? “Forty years and over is the population group I’m interested in. Until the age of about 40, you don’t need to worry too much unless you want to play sport. But the group between 40 and 60 – that’s when life gets difficult, because you have children, elderly parents, a busy job and commuting.
“And then, from 60 onwards, of course many people retire. That gives them the opportunity to do more, but they have the negative belief that activity is only for young people, so they join the bridge club or the bowls club instead.
“That’s why I wrote my latest book, Sod Sitting, Get Moving! in collaboration with Diana Moran.” This on the back of several other books, including The Walking Cure, Midlife and Sod Seventy! A follow-up to The Walking Cure, entitled Walking Plus, will be out later this year.
“People are very poorly informed about the benefits of exercise,” concludes Gray. “Most people think what old people need is for more to be done for them. We need to change this mindset. Everyone involved in the fitness industry should go and see their local MP, take them a copy of Sod Sitting and say: ‘We have to try and reduce the amount of time people spend in long-term care by getting them fitter.’”
INTRODUCING SIR MUIR GRAY
Sir Muir Gray is a public health doctor, a consultant in public health for Oxford University Hospital Trust and a professor at Oxford University. He also dedicates a day a week to the promotion of healthy ageing.
He was the first Chief Knowledge Office for the NHS and set up NHS Choices, and was also the founding director of the NHS National Screening Programmes, establishing programmes for cancer and aortic aneurysm screening specifically for older people.
He also runs a company called Better Value Healthcare, which focuses on ensuring resources in the health service are allocated in a way that maximises value. He explains: “We identify low value activity in the health service and we switch those resources. For example, we probably spend £1bn in the last year of life over-treating people who wanted to die at home. Is that high value? Better Value Healthcare looks for lower value activity and switches resources to higher value activity.
“It isn’t just about prevention – it’s treatment too. Treatments we’re not doing enough of, but where we have to switch resources from treatments that are less effective, of lower value, to be able to afford them.”
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