Long-term implentation and effects of the National Exercise Referral Scheme (NERS) in Wales

Lead investigator
Kelly Morgan

Co-contributors: Graham Moore

The proposed project will evaluate the post-trial implementation and long-term clinical effectiveness of the Welsh National Exercise Referral Scheme [NERS] across all 22 Local Authorities [LAs] in Wales. Physical inactivity is a major cause of preventable illness and significant cost to the NHS. In Wales, 71% of adults are not sufficiently active. Increasing physical activity at the population level, and among at risk groups, is a public health priority. While an earlier evaluation of NERS revealing promising impacts upon self-reported physical activity and mental health outcome at 12-month follow-up, the ongoing fidelity of implementation and long-term effectiveness on health outcomes is unknown; understanding the longer-term maintenance of implementation and effects of evidence-based interventions is a major empirical gap in the public health literature. What evidence there is to date suggests that evidence-based interventions are often not widely adopted or are adopted with insufficient quality and fidelity following trials of their effectiveness. Furthermore, use of self-reported outcomes may have subjected data to inaccuracies and the follow-up of participants in the longer-term may be necessary to demonstrate significant improvements in a variety of health outcomes. This proposal aligns with Welsh government strategy which identifies physical activity as a priority area. It addresses NICE research recommendations, as well as service delivery recommendations of Public Health Wales’ Health Improvement Review, focused on furthering the impact of NERS through innovation and research.
Aims & objectives
Aims and objectives The overarching aim of this study is to evaluate the long-term implementation of NERS across Wales and to examine the long-term clinical effectiveness of the scheme, in order to quantify the sustainability and effectiveness of the national scheme. This will be achieved by: • Investigating the acceptability, adherence, fidelity and dose at which the programmes core components are delivered within a LA over time and across LAs; • Examining long-term health outcomes of NERS patients at 3- and 5-year time points following scheme exit. The objectives and research questions (RQ) are: Objective 1: To explore experiences of programme implementation since the programme evaluation and national roll-out. RQ1: How consistent has the long term implementation of NERS remained with the key findings and recommendations of its evaluation? RQ2: How and to what extent has the intervention and its context adapted to one another over time? Objective 2: To examine the schemes long-term effectiveness on NERS patient’s health outcomes. This objective will address the following research questions: RQ3: How do patient adherence rates vary across schemes and within schemes over time? RQ4: Does implementation predict differences in adherence rates within- and between schemes over time? RQ5: Do NERS patients have better long-term health outcomes in comparison to comparative individuals in the general population? RQ6: To what extent does the implementation quality of NERS effect long-term clinical outcomes?
Study design
Research plan

This research will consist of two phases; 1) qualitative study investigating the acceptability, adherence, fidelity and dose at which NERS core components are delivered within a LA over time and across LAs and 2) quantitative study examining long-term health outcomes of NERS patients at 3-and 5-year time points following scheme exit. Within phase 1, structured/ semi-structured interviews will be conducted to explore experiences and views of programme implementation. Phase 2 will involve secondary data analysis of routine NERS data and record linkage to anonymised routine health records. The use of propensity-score matching will enable long-term health outcomes to be compared between NERS patients and non-NERS patients. This phase will also involve subgroup analyses to determine effectiveness of NERS within specific populations.




NERS is delivered in a variety of settings across the 22 local authorities in Wales, including council owned leisure centres and private gyms. For this project, we will gather data from scheme implementers (i.e. NERS national coordinator and area coordinators) across all 22 local authorities. Data will also be gathered from exercise professionals in a purposive sub-sample of four case-study areas. Routinely collected data from all NERS participants who were entered into the NERS generic pathway will be used.