UK Physical Activity Services

Health service provision is where the SEM clinician has most direct influence. It includes brief advice delivered opportunistically in primary care, exercise referral schemes, structured programmes such as cardiac and pulmonary rehabilitation, physiotherapy, and increasingly social prescribing through link workers who connect people to community activity. In England, local authorities carry statutory public health responsibility and hold major population-level levers, particularly planning, active travel, public space and leisure provision, including leisure centres, parks and green space, cycle lanes and safe walking routes. Their funding comes principally from the ring-fenced public health grant and general council budgets, both of which have been under sustained pressure, which is why provision differs so markedly between neighbouring areas.

The voluntary and community sector delivers much of what people actually use, including walking and running groups, disability sport organisations and condition-specific charities, typically funded by grants and donations and often more effective at reaching groups the formal system misses. Commercial providers, from gyms to personal trainers to apps and wearables, are paid for directly by the user, and that user-funded model creates an important affordability barrier for people on lower incomes. Across all four sit national and regional sport and physical activity agencies, which distribute funding, run campaigns and coordinate strategy. Internationally the same functions are arranged differently: the World Health Organization sets global targets and its global action plan on physical activity provides the framework most countries work within, while delivery models range from insurance-funded programmes to municipal provision.

Commissioning is the process of assessing need, deciding what to secure, arranging delivery and holding providers to account, and it is worth understanding because it explains why services appear and disappear. Local needs assessment identifies the problem and the groups affected, and commissioners then specify a service and its outcomes. Delivery is arranged in several ways, not only by competitive tender for a fixed-term contract: grants, in-house delivery, partnerships, and commissioned NHS or voluntary sector services are all common. In England, the Health and Care Act 2022 placed integrated care systems on a statutory footing, each comprising an integrated care board responsible for NHS commissioning and an integrated care partnership bringing NHS and local authority partners together, which creates real opportunities to align physical activity provision with health priorities rather than commissioning it in isolation. In practice, short contract cycles, annual budget uncertainty and outcome measures that favour throughput over reach all shape what gets delivered.

Guidance on exercise referral schemes in England is specific and frequently examined, and it is more restrictive than many clinicians expect. Commissioners are advised to fund schemes only for people who are sedentary or inactive and who also have an existing health condition or other factors putting them at increased risk of ill health, and specifically not for people who are inactive but otherwise apparently healthy, for whom brief advice is recommended instead. Even for the eligible group the recommendation is conditional: schemes should be funded and used only where they incorporate recognised behaviour change techniques, collect baseline, follow-up and process data, and make that data available for monitoring and evaluation. The reasoning is economic rather than dismissive, since the additional effect of a referral scheme over brief advice is small while the cost is considerably higher. It is worth noting that this guidance excludes structured disease-specific programmes such as cardiac and pulmonary rehabilitation from its definition of an exercise referral scheme. For the clinician the practical implication is that a referral is not automatically the right response to inactivity, and that for an inactive but otherwise apparently healthy adult, brief advice rather than exercise referral is what guidance recommends.

• •Provision spans four sectors: the health service, local authorities, the voluntary and community sector, and commercial providers, with sport and physical activity agencies working across them.
• •In England, local authorities hold statutory public health responsibility and major population levers, particularly planning, active travel, public space and leisure, funded through the ring-fenced public health grant and council budgets.
• •Commercial provision is funded directly by the user, which creates an important affordability barrier for people on lower incomes.
• •In England, the Health and Care Act 2022 placed integrated care systems on a statutory footing, comprising an integrated care board for NHS commissioning and an integrated care partnership bringing NHS and local authority partners together.
• •Guidance in England advises funding exercise referral schemes only for inactive people who also have a health condition or risk factors, and only where the scheme uses behaviour change techniques and collects baseline, follow-up and process data.
• •For inactive adults who are otherwise apparently healthy, brief advice rather than exercise referral is recommended, because schemes add only a small effect at considerably greater cost; disease-specific rehabilitation programmes are excluded from the definition of a referral scheme.