Persistently high levels of physical inactivity constitute a public health problem globally [1]. Physical inactivity contributes to chronic diseases which are a burden to health care systems such as the National Health Service (NHS) in England [2, 3]. There remain stark inequalities when it comes to how physically active people are and the following groups are particularly affected - older people, people living in more deprived areas, people living with long term conditions and/or physical or learning disabilities and, people in Black, Asian and Minority Ethnic groups [4]. More positively, increasing physical activity has been shown to improve health and wellbeing at every age and in diverse populations [5, 6].
Growing recognition of the issue of physical inactivity has resulted in the publication of numerous policy drivers and strategies advocating for physical activity, including the World Health Organization’s Global Action Plan on Physical Activity 2018–2030 - More Active People for a Healthier World [7]. Investment in policies that promote physical activity can contribute positively to achieving many of the 2030 United Nations Sustainable Development Goals [7, 8]. In 2013, the World Health Organization pledged to reduce global physical inactivity prevalence by 10% by 2025 [9]. However, findings from a pooled analysis of population based survey data suggest that if current trends continue the target will not be met [10].
The COVID-19 pandemic and the necessary measures to suppress the virus has resulted in further reductions in population physical activity levels, particularly for communities with the highest health needs [11, 12]. It has led to calls for an update to the Global Action Plan on Physical Activity (GAPPA) to reflect the ‘new’ state of physical activity [13]. Arguably, COVID-19 has made physical activity promotion even more urgent and provides significant opportunities for renewed action in this area.
Tackling low levels of physical activity has been an identified priority of successive UK governments (responsible for health policy in England), resulting in the publication of numerous documents, including as a legacy commitment of the London 2012 Games, [14, 15] and the UK government’s Advancing Our Health: prevention in the 2020s Paper [16]. Some progress has been made in tackling low levels of physical activity, though it has been slow and inequalities remain for people with health issues and other groups [17]. Notably, a recent critical review of national physical activity policies in England identified 54 policy documents in circulation relating to children and young people alone [18]. This suggests that there remains a need to better connect and align policies and strategies and how best to coherently disseminate and communicate key messages to various audiences. In 2021 Sport England, a UK government body responsible for growing and developing grassroots sport and getting more people active across England published its timely Uniting the Movement strategy [19]. The strategy prioritises connecting physical activity with health and wellbeing as critical to get the population active, and provides a real moment to harness and align action through a long-term whole systems approach. There is also increasing political recognition of the importance of the link between physical activity and population health and wellbeing, including a call for a ‘national sport, health and wellbeing plan’ and creation of a new ministerial post with accountability within the Department of Health and Social Care [20].
Whole systems approaches to physical activity
There is growing interest in the public health field in whole systems approaches to population health in general, [21] and such approaches related to promoting physical activity in particular [22, 23]. Rutter and colleagues in 2017 described a complex systems model of public health in which poor health and health inequalities are conceptualised “as outcomes of a multitude of interdependent elements within a connected whole. These elements affect each other in sometimes subtle ways, with changes potentially reverberating throughout the system” [24]. This was followed in 2019 by a paper calling for whole systems approaches to global and national physical activity plans [22].
The Global Action Plan on Physical Activity suggests that whole systems approaches are needed to combine upstream policy actions, which aim to improve social, cultural, economic and environmental factors that support physical activity, with downstream individually-focused approaches [7] It also highlights the need to scale-up policy actions and government strategies for physical activity. Whole systems approaches are arguably relevant and necessary to address low levels of physical activity, associated negative health impacts and wider outcomes in at-risk population groups including people from more disadvantaged communities. Physical inactivity intersects with a range of inequality issues associated with environments that discourage physical activity, including lack of access to green spaces, transport planning traditionally focused on car travel, lack of adequate infrastructure for walking and cycling and cultural attitudes towards physical activity [25].
In England, the Office for Health Improvement and Disparities (OHID), has responsibility for promoting physical activity and health (and has a lead role in promoting whole systems approaches to physical activity through the Everybody Active, Every Day framework [26]). Prior to its cessation, Public Health England had invested in systems thinking and in 2019 published Whole systems approach to obesity: a guide to support local approaches to promoting a healthy weight that, though focused on obesity, included the promotion of physical activity within its scope [27]. The development of the Everybody Active, Every Day framework [26] involved over 1000 national and local stakeholders to help address inactivity and increase physical activity. The framework promotes a whole systems cross-sector approach across four domains – active society; moving professionals; active environments; and, moving at scale. Shortly afterward the UK government published its strategy for sport and physical activity, Sporting Future, which for the first time identified improvement of health and achievement of the UK Chief Medical Officer’s guidelines on physical activity as specific ambitions [28].
In recent years, at a national level in England there has been a growing collaboration across sectors led by OHID and Sport England, which has tested opportunities to enable the NHS and healthcare professionals to do more to promote physical activity as part of routine care [29]. For example, Sport England have recently been working on local delivery pilots (LDPs), where 12 LDPs across England have developed and piloted whole system approaches to physical activity in local communities [30]. At a more regional level, it is pertinent to note the work in Sheffield and the Move More Sheffield whole systems approach which has helped inform ‘what works’ to promote physical activity through the co-location of healthcare and leisure settings [31, 32].
There exist many different perspectives on whole-systems approaches, with systems language sometimes used differently. This definition describes how whole systems approaches are understood in this paper:
‘A local whole systems approach responds to complexity through an ongoing, dynamic and flexible way of working. It enables local stakeholders, including communities, to come together, share an understanding of the reality of the challenge, consider how the local system is operating and where there are the greatest opportunities for change. Stakeholders agree actions and decide as a network how to work together in an integrated way to bring about sustainable, long-term systems change.’ [33]
The NHS, whole systems approaches and systems leadership
In England there is a concern for the health of the nation and the impact that an ageing and increasingly unhealthy population has on the financial sustainability of the NHS and wider public sector [34]. A recent LSE-Lancet Commission on the future of the NHS highlighted the unsustainability of the service and the critical need to focus on improving the population’s health through prevention and health promotion [35]. This echoes the previous NHS Long Term Plan, [36] which called for a step change in action on prevention and a shift of resources from acute care to prevention. There remain challenges when it comes to public health funding and so whilst the latest public health budgets for 2021–22 in England represent a numeric increase, [37] budgets remain substantially lower than in 2015 [38,39,40].
Historically service delivery metrics such as performance, quality and finances have been prioritised as key performance indicators rather than prevention of ill-health and promotion of health and wellbeing [41]. Research indicates that supply of healthcare and, presumably to some degree, the actions of NHS system leaders are driven by responding to government decision and policy choices and, perhaps to a lesser degree, population health goals [42]. Moreover, there is little evidence of substantial central pressure for their involvement in long-term prevention initiatives [43]. Evaluations suggest that leadership development programmes undertaken by NHS managers and clinicians tend to focus on systems leadership and address change management in service delivery, quality or training rather than in embracing new approaches to integrating prevention into NHS services [44]. To have a significant impact on population health, NHS leaders will need to embrace a concept of systems leadership that goes beyond the health care system and acknowledge the importance of the wider and more complex social determinants of health and thus the need to work with multiple stakeholders (e.g. local authorities, education providers, criminal justice system, private sector) across their local systems [45].
“Promoting health through the organised efforts of society” is fundamental to the role of public health [46]. The shift of the local public health function from the NHS back to local authorities in England in 2013 is generally agreed to be good in principle, as local authorities are well placed to address the wider social determinants of health. However, it has proved a barrier to the NHS embracing prevention as the NHS lost the direct employment of most of its public health experts. It has also naturally created a challenge for engaging the NHS in public health objectives, for which there is opportunity to address this. The lack of a public health perspective in the NHS has been recognised and there now exists Regional Directors of Public Health [47].
The advent of integrated care systems
The NHS Long Term Plan [36] strongly expressed the policy intention to shift the focus of local NHS organisations to population health management through the establishment of integrated care systems (ICSs) covering the whole of England [48]. ICSs are intended to integrate across primary and specialist care, physical and mental health, and health and social care. In the absence of an agreed national model of the ICS, Fig. 1 presents a model of the integrated care system in Bolton, England [49]. In addition, there is a strong emphasis on prevention, although much of the focus is on secondary prevention for conditions including diabetes, obesity and respiratory illness. There is some attention given to the need for upstream interventions such as tackling air pollution, but little indication of a whole systems approach to primary prevention and no mention of the need to promote physical activity.
Similarly, the White Paper Integration and Innovation [50] states a clear commitment to integration of prevention and health and care services. However, as above, the prevention agenda is more focused on secondary rather than primary prevention. In particular, action on obesity is given a high profile, but there is no reference to physical activity nor is the action proposed on obesity reflective of a whole systems approach. By contrast, the Advancing Our Health: prevention in the 2020s Paper [16] emphasises the potential for ICSs to contribute to both primary and secondary prevention.
It is clear that ICSs are intended to take a whole systems approach to prevention and the integration of health and care services [51]. This is reaffirmed in the government’s policy paper Transforming the public health system: reforming the public health system for the challenges of our times, [52] which encouragingly signals the intention to strengthen the NHS role in prevention of ill-health, and articulates the requirement for ICSs to partner with non-NHS bodies when it comes to population health and meeting local needs. This policy paper also helps to set out the future for health improvement and public health and, at a national level, sets the scene for the recent establishment of the Office for Health Improvement and Disparities.
The project to engage NHS systems leaders in whole systems approaches to physical activity
Despite health care being one of the top eight best investments for increasing physical activity, [53] there are few published studies that examine how to involve health system leaders in whole systems approaches, [54] and none we identified which address how to involve the NHS in promoting physical activity in particular. To help address this lack of evidence, Public Health England commissioned the University of the West of England, Bristol (UWE Bristol) to carry out qualitative research exploring experiences of engaging NHS leaders in whole systems approaches to physical activity. This project has been reported elsewhere, [54] but briefly, eight interviews were conducted with national stakeholders working across England in different parts of the system, including for example, those from NHS England and NHS Improvement (NHSE&I) and the Local Government Association. The aim of these interviews was to gain a high-level overview of NHS engagement in whole systems activity. National interviews were complemented by interviews with 22 local informants from four case study sites in England that were identified as implementing whole systems approaches to physical activity. Two case study sites were Local Delivery Pilots (LDPs) and two were not. The four local practice examples presented diverse contexts and approaches to engaging NHS leaders in whole systems approaches to physical activity, but all had done so to different degrees. Local informants from each case study site were purposively sampled to represent different levels of the local system. Data were thematically analysed [55] and ten key themes identified (Additional File 1). The study was granted ethical approval by the University of the West of England Research Ethics Committee (Ref: HAS.20.01.095).