Active travel on prescription? The NHS needs some medicine too

Covid-19 has laid bare the many long-term inequalities in society that are unaddressed. Respite from the continuing sadness and uncertainty of daily news headlines is possible by contemplating the positive directions that could be taken to address these inequalities as we emerge from the pandemic. 

I recently made the uncommon transition from cycling researcher to General Practice nurse, so the boom in bike sales and journeys has been a welcome development during a first year of nursing that has seen events I could never have anticipated.

Those working professionally to deliver active travel improvements in the UK learn quickly to treat with caution grand policy announcements of a step-change in provision for cycling, such as the “bold vision” for cycling and walking heralded in the Government’s new Gear Change policy announcement. But this, and proposed changes to the Highway Code, suggest that the Prime Minister has grasped the serious implications of having the third highest rate of obesity in Europe. The call to re-balance in favour of active travel modes is long overdue. However, based on remaining differences in funding levels between road building and cycle infrastructure, we should remain sceptical about whether the ambition is serious and will be realised.

My final research with the Centre for Transport & Society at the University of the West of England was a three-year study, Cycle Boom, that considered factors that enable and discourage cycling among older people. I interviewed people aged 50 to 80 about their life histories of cycling to understand the contexts for successful continuation of cycling, for re-discovering cycling in later life, for disengagement from cycling and for absence of cycling. Accounts of continuous cycling and its re-discovery revealed many empowering and enabling physical, social and cultural influences. Reasons for diminished motivation or confidence were similarly multifactorial. Changes in cycling activity were often linked to life events: starting a career, moving job or home, having children, a change in health status, and becoming a carer.

Similarly with patients now, I regularly discuss physical activity, often in the context of an annual review of a long-term health condition. I have at the back of my mind those personal accounts of cycling from the research. So the most eye-catching proposal in Gear Change to me was obviously the plan to pilot GPs prescribing cycling (LTT 07 Aug).

If the aim of ‘cycling on prescription’ is improved public health, my fear remains that the Prime Minister is stuck in the wrong gear at the bottom of a steep hill. 

I ground my conversations with patients by exploring the physical activity they undertake, be that through walking, gardening, housework, DIY, childcare or dance. Where possible, I lead the conversation on to discuss the additional benefits more physical activity is likely to have for other issues they may be experiencing: improved mood, sleep, managing stress and anxiety, social interaction, and maintaining strength, flexibility and balance, alongside the better known effects on weight management and cardiovascular risk.

My experience suggests there is much more to be considered beyond simply pushing physical activity up the clinical agenda in a time-pressed consultation. Cycling on prescription is a promising and coherent tool for health promotion suited to delivery through primary care, but discussions in a consultation need to be empowering and enabling to the patient, and individualised to their circumstances, their interests and their motivations. The conditions my patients face locally suggest very few would be able to initiate or resume cycling. Clinicians will be cautious about laying unrealistic expectations on patients because it may undermine any already established rapport and influence, with consequent detrimental effects on the overall management of a patient’s condition.

The scale and reach of the NHS through its workforce, estate and supply chains is huge, and the NHS, through its management actions, could have a commensurately enormous impact on cycling and active travel. Arguably, this is just as, if not more important than, cycling on prescription, with impacts at population level, and not just for patients.

The NHS workforce is replenished every year with individuals who train and go on to have long careers with the organisation. Cycle Boom, and other research, indicates that changes in employment, and in particular the transition from education to employment, can be key turning points for establishing, and then locking in, travel habits. These behaviours can then also influence the travel resources, attitudes and behaviours of other members of a health worker’s household.

The conditions my patients face locally suggest very few would be able to initiate or resume cycling. Clinicians will be cautious about laying unrealistic expectations on patients because it may undermine any already established rapport and influence.

As a student nurse, I continued to commute by bicycle but, in a cohort of 200, I knew of just two other nurses who did likewise. Tax-efficient cycle purchase schemes are not available to student health care professionals, and there was no direct promotion of cycling as a healthy and affordable choice for my future career.

For my clinical training, I was based at a recently built hospital that offered a secure cycling compound and purpose-built changing rooms. These facilities were regularly used to capacity and were a level of cycling provision uncommon across the NHS footprint. The location of NHS premises within many local communities presents an opportunity, through provision of cycle storage and infrastructure, to increase the visibility of cycling in places that have low levels of cycle use.

The provision of modern health care is a transport-intensive business. Besides the more obvious movement of people, every NHS site generates a vast number of logistics-related trips required to deliver clinical and non-clinical resources, prescriptions, specimens to laboratories, and equipment and disposables to patients at home.

So, while the principle of cycling on prescription is good, there remain issues with the way clinicians can realistically promote cycling. Conversely, the NHS has the opportunity, through the management of its transport and logistics, to positively influence the conditions and experiences of cycling for many communities. 

Heather Jones is a primary care nurse and was formerly a research associate in the Centre for Transport & Society at the University of the West of England, Bristol.