The role of primary care in reducing the decline in physical function and physical activity in people with long-term conditions; what works, for whom and in what circumstances? A realist synthesis of evidence.

Principal / Lead investigator
Co-investigators / research team
Type of study

Evidence synthesis with embedded stakeholder co-production and co-design


Aims: Your ‘physical function’ describes how well you can perform activities that are essential for daily living and staying independent, such as walking to the shops or standing up from a chair. People with long-term conditions, such as arthritis or diabetes, often become less able to do these tasks and are less physically active. The number of people living with long-term conditions is increasing. The purpose of this research is to work with patients and health professionals to work out how best to help people with long-term conditions maintain and improve their physical function and become more physically active.

Background: People with long-term conditions visit their GP surgery for regular check-ups and it is the first place they visit with their symptoms. However, physical function is not given as much priority as other measurements, such as body weight or blood pressure. If a person’s physical function is poor, it means they are less able to look after themselves and do things they enjoy. Improving physical activity is an important way of improving physical function and is very helpful for many long-term conditions. Despite this, most people do not do enough physical activity. Therefore, it is important to pay attention to physical function and physical activity when a person visits their GP surgery. It is also important to consider psychological and social factors. However, we do not know the best way to address physical function and physical activity when people visit their GP surgery for regular check-ups.

Methods: We will examine previous studies that have looked at improving physical function and physical activity in primary care. Rather than only finding out whether or not something works, we will find out what works (or doesn’t work), for whom and in what circumstances. This is especially helpful when investigating complex areas, such as improving physical function and physical activity. We will start by developing working theories about why some interventions have worked in primary care or others have not. We will talk to patients and health professionals involved in improving physical function and promoting physical activity to help us with this. This will help us refine our working theories. We will also describe these theories clearly and check that they make sense, including with patient and public representatives. We will end up with a final set of recommendations about how best to help people fulfil their functional potential when they visit their GP surgery. These recommendations will be taken forward to the ‘co-design’ stage. This stage will involve three creative workshops during which two to three ideas of new ways to improve physical function and physical activity will be developed. There will also be a workshop to develop ways of sharing the new findings from the study. A wide range of patients and people involved in the care of people with long-term conditions will be invited to participate in these workshops.

Dissemination: We will invite patient, public and professional representatives to be involved in our dissemination activities. Two research publications will be written. One will focus on how we completed the project and one will focus on the findings and recommendations. Reports will be written for the NIHR and we will write to everyone who took part. We will also present our findings at scientific meetings and share with professionals and with the public in a variety of ways, such as by making a video.

Lay involvement

People with long-term conditions have been involved throughout the development and design of this proposal. As part of our work for Public Health Wales, we interviewed people with arthritis about ‘lifestyle management’. This stimulated our ideas for the current research questions. Philip Bell was a PPI representative for this work and has continued to be involved. Candida Lovell-Smith joined PB from the beginning of this proposal and they are now both co-applicants. 

The PPI team have been at the centre of decision-making when shaping the proposal ideas and plans. Through their contribution to proposal development meetings, they have highlighted potential psychosocial influences on physical function and physical activity interventions, which we will consider as part of the synthesis. They have made insightful comments and helped to write the ‘detailed project description’, ‘lay summary’ and sections relevant to PPI (including PPI costings). In particular, they have used their experience to suggest ways they could be involved to give a PPI perspective but also help with data collection, interpretation, dissemination and implementation. 

This project involves public/patient involvement (PPI) at every stage in order to contribute to the co-production of the initial programme theories, refining and testing, developing recommendations, co-design of ideas and recommendations for primary care service innovation, knowledge mobilisation and dissemination. In addition, the PPI co-applicant team will be involved throughout as equal project members. PPI representatives will attend Project Advisory Group meetings and will be invited to help researchers identify additional patient groups, charities and other relevant stakeholders for the workshops, develop and refine working theories and help develop participant documentation as appropriate. They will be invited to become involved in facilitating workshops and will have active input in the knowledge mobilisation phase. We will encourage and acknowledge PPI contribution in scientific papers and reports.

How could this research potentially benefit patients?

This research could potentially benefit patients because long-term conditions comprise the biggest burden on the NHS involving more than half of all GP consultations, 65% of out-patient visits, and 70% of inpatient bed days. Their prevalence rises with age, affecting 50% of people aged 50 years and 80% aged 65. As older people accumulate more long-term conditions, they become increasingly frail and are at higher risk of falls, disability, admission to hospital and the need for long-term care. In order to address this burden, a new way of managing and preventing this, is needed.

To our knowledge, this will be the first realist synthesis of physical activity interventions designed to improve physical functioning for patients with long-term conditions managed in primary care. In addition, it will combine findings from the realist evidence synthesis with co-developed service innovation ideas, to provide recommendations for primary care delivery. The synthesis findings will lead to actionable recommendations for those involved in the organisation of health services, in particular primary care and their partners, for the benefit of patients.

Who is the study sponsor?

Bangor University

PROSPERO registration



National Institute for Health Research, Health Services and Delivery

Total grant value


Start date


End date


Further information

Project summary on NIHR website: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/174522/#/

Outputs generated (Reports / Publications / Impact)

Prior to the project commencing, the study team have published the following opinion piece relevant to this project: ‘Putting function first: redesigning the primary care management of long-term conditions’ Br J Gen Pract 2018; 68 (673): 388-389. DOI: https://doi.org/10.3399/bjgp18X698249