Episode 1 - Autonomy, Relatedness and Competence

The episode discusses the challenges faced by individuals with long-term health conditions who lack support to maintain physical activity after clinical settings. It explores the importance of access, integration, motivation, and support in community-based physical activity programs for such individuals. Emphasizing the need for autonomy, relatedness, and competence, the episode highlights how normalization process theory and self-determination theory can help individuals like John, who has had a stroke, transition to incorporating physical activity into their daily lives. The benefits of community-based physical activity in managing long-term health conditions are underscored, with a focus on its cost-effectiveness and effectiveness in care pathways. Despite its potential, barriers such as limited clinician time, lack of training, and systemic blockages hinder the integration of community-based physical activity into care pathways. Solutions to address these challenges are to be explo Today's episode is about a very specific problem. What happens after someone with a long-term health condition is told to be active, but then lacks the support to actually make that happen? People with long-term health conditions are often introduced to physical activity in a clinical setting after a diagnosis. That first step matters. But too often, once clinic or hospital-based support ends, people are left without a clear, confident route into something they can keep doing in everyday life. That gap is what this podcast is here to explore. It is for clinicians, community providers, and anyone involved in shaping care pathways for people living with long-term health conditions. Across this episode, I'm going to keep coming back to four themes. Access, integration, motivation, and support. Access is how people find and reach activity. Integration is about how activity becomes part of care pathways and everyday routines. Motivation is about why people start and keep going with activity. And support, especially peer support, is about that sense of someone like me that makes getting involved easier. When those things are missing, familiar patterns emerge. No referral, low confidence, patchy attendance, and activity never really becomes part of everyday life. When they are in place, the picture changes completely. Before I begin, I should probably provide some clarity on scope. When I talk about long-term health conditions here, I mean conditions that last more than a year, can't currently be cured, and need ongoing management, treatment, and support. This covers degenerative and progressive conditions like Parkinson's disease, dementia, stroke, and cardiac, and others that bring lasting symptoms, reduce function, and have a significant impact on daily life. What I'm not talking about are acute or unstable phases, where exercise isn't safe until medically stabilized. So, community-based physical activity. What is it? Why do it? And how can it be delivered? And how do we get people to engage with it? To answer these questions and bring them to life, I'm going to use an example throughout this episode. Let's imagine someone called John, who has recently had a stroke. John has completed some structured clinic-based rehabilitation. It has been useful, but it's also been time-limited, medically supervised, and focused on a fixed outcome, such as discharge, or an accepted level of independence. So, what happens next? How do we help John to make the step from doing activity because he is told to, to doing it because it's part of his everyday life? Two ideas can be used to support that shift. The first is normalization process theory, or MPT. Put simply, MPT helps us to understand how new ways of doing things become part of everyday life. The second is self-determination theory, which I will refer to as ARC. Autonomy, meaning choice. Relatedness, meaning connection. And competence, meaning confidence and capability. If John doesn't really have choice, his motivation drops. If he's unsure what's safe, his confidence drops. And without that sense of connection, it becomes much harder to start. Community-based physical activity works best when those needs are supported. In the rest of this episode, I'll explore how it does that, and what gets in the way when it doesn't. At its most effective, community-based physical activity includes shared planning to decide what activities work best. Practical teamwork that makes every session doable for everyone involved, is delivered in accessible community spaces, and includes ongoing reflection that builds group confidence and keeps people coming back. For John, it will be built around what he can do, not what he can't. He needs to be able to help shape the delivery through his feedback. And it will be for the long term, building something that lasts. This will help John to form lasting habits, building his confidence and creating social connections. Success here isn't short-term attendance. It is self-sustained, directed participation over time. In contrast, poor provision, in clinic or in the community, may lack the shared planning and group teamwork needed to embed the activity into his daily routines. It's more directive than collective. This is where it really shows up, because poor provision will focus on compliance over choice, which can limit autonomy and relatedness, making it harder to build intrinsic motivation for ongoing participation. When those needs are met, provision is much more likely to stick. But what does that look like? Community-based physical activity programmes typically offer condition-specific classes and or broader sessions tailored to age and ability. Instructors may specialise in the health condition, the activity or both. For example, John might join a circuit class led by an instructor who knows both his condition and circuit training inside out. They can share specifics, like how exercise affects medication absorption. Or he might join a boxing class with a coach with deep boxing knowledge, but little expertise around his condition. They keep the activity safe and effective by watching participants closely and tweaking the sessions to match each person's ability. In each case, done well, they are supportive and tailored and more than just exercise, giving John choice over activities he enjoys, building his confidence through the right level of challenge and strengthening connection through the group. For John, the beneficial connection between community-based physical activity and his long-term health condition may be clear, but why should it matter to clinicians and commissioners? The NHS's annual budget sits around £195 billion, with roughly 70% going towards treating long-term health conditions. And we know that physical activity already saves the NHS billions each year. For commissioners, this isn't about funding something entirely new. It's about making better use of existing community assets and connecting them more effectively into care pathways. Community-based physical activity has a unique edge over other interventions because it meets people where they are, in common settings, not clinics, through programmes which deliver accessible, affordable and social ways to build health and manage conditions effectively. So while the case for community-based physical activity is strong, the real question is how this actually plays out in practice for people living with long-term health conditions. When we move from the evidence to the lived experience, the pathway isn't always as clear or consistent as it should be. Thinking about John again, what does a good pathway look like? Picture a straightforward flow. You spot symptoms, get a diagnosis, start medical treatment, then get signposted straight to community-based physical activity for ongoing treatment. In an integrative pathway, this signposting isn't an add-on or more work for clinicians. Instead, it's an additional short conversation about physical activity during an existing consultation. In practice, this could be as simple as a GP having a short, focused conversation supported by a local activity director and then directly linking John to a community provider rather than just advising him to be more active. And from a community provider perspective, it means having a clear, welcoming entry point, making it easy for John to get started, taking the time to understand what matters to him and helping him to settle into the group so he's not walking in alone. But for many people, the reality is decidedly different. Integrating activity into care pathways is patchy and tricky. If you're lucky, your health professional will be a strong advocate, but even then, it might not be available or the conditions for you to receive the information might not be right. You may lack motivation or peer support. If you're unlucky, time pressures on clinicians, gaps in training, worries about patient motivation or physical limits can all inhibit the pathway. My deep rough work drawing on questionnaires and focus groups with clinicians, community providers and people living with long-term health conditions shows that even among those who view community-based physical activity as a solution to rising healthcare costs and missed opportunities for prevention, referrals and delivery still falter. What this highlights through an NPT lens is a failure of collective action and reflexive monitoring. Programs exist, but they are not consistently enacted or evaluated within routine care. Key blockers include a lack of peer support, the R of the arc, relatedness, that vital someone like me to guide and support, workforce capacity, insufficient numbers of people skilled in signposting and delivery, feedback loops, a failure to track real impacts and not enough time dedicated to behaviour change to drive lasting shifts, all play a part in reducing the likelihood of integrating community-based physical activity into care pathways. These blockers can be addressed and that is part of what I'll be covering in future podcast episodes. Before exploring solutions, it's worth digging deeper into those barriers, which are not just minor hurdles, they're systemic blockages. Because they're exploring them in more detail, it becomes obvious that they need to be addressed. Clinicians are swamped. Short appointments leave little room to chat about physical activity. Even with resources such as moving medicine, time and opportunities can be limited. And without dedicated training in community-based physical activity options or how to frame conversations that emphasise its safety and benefits, they can default to cautious approaches such as wait for your specialist or arrest his best philosophy. For commissioners and clinicians, these time and training gaps put added pressure on budgets and can lead to a quick fixed approach such as the prescription of a medication which further strains finances and manages symptoms, not the cause. For community providers, access is key. This isn't just about delivering sessions. It's about creating the kind of environment that people feel confident walking into and want to come back to. In places like North Yorkshire, distance matters. There can be a lack of safe nearby venues or cost can be a barrier. Activities may exist, but are they nearby, affordable and easy to find for the target audience? Referral routes can also be patchy. Some GPs are able to link to specialist programmes. Others don't know where they are or they may practise in areas where they don't exist. From John's point of view, this can be frustrating. He's told being active matters, but not shown how to do it. John may pick up on cautious language from those around him, including professionals, but often family members as well, particularly in the early stages when the rest is best narrative is most likely to prevail. All of this can lead to low motivation. If John doesn't feel he has choice, autonomy drops. If he's unsure what is safe, confidence drops. And if he doesn't feel connected, it becomes much harder to start. When the system doesn't work, these barriers and more stack up into a loop. People fall through the gaps, no referral, no confidence, no support, and activity never becomes part of daily life. To combat the barriers, we need to develop enablers, the things that make integrating community-based physical activity into care pathways easier. And just as these barriers are systemic, the enablers need to be too. Built-in shifts that make community-based physical activity a normal part of everyday life. Enablers should form a connected network, clear, confident clinician messaging, reliable referral pathways, trusted local connectors. And this is where peer support really matters. When talking to people with long-term health conditions, many of them spoke about their initial fear of getting involved in an exercise class, which I think is something most of us can relate to. That first time, walking in alone, unsure if you're fit, not knowing anyone. How much easier is it when we know someone in the group, the classic someone like me? In this context, another person with a similar long-term health condition, who's been there, understands your daily reality and cheers you on, or occasionally takes the mickey, whatever works at the time. That's peer support. Not just company, but advocacy, shared experiences, and that vital sense of belonging. In one example from my research, members of a boxing for Parkinson's class told me that when they first heard about it, they didn't think it was for them, but it was existing participants encouraging them to come along that got them through the door. And once they'd taken part, it was that shared sense of achievement, and sometimes relief, at the end of each session that kept them coming back, building both their confidence and that sense of connection with others in the group. This is relatedness in action. Connection. My DPROF research, drawing on focus groups with people with long-term health conditions, shows that it's often peer support, not a clinical referral, that first encourages people to start. And that sense of relatedness is one of the things that contributes most to them sticking with programmes. For John, this is the difference between hearing about something and choosing to do it, between knowing it's good for him and believing it's possible. That brings me back to the four themes, access, integration, motivation, support. When those four things are missing, the opportunities that community-based physical activity offers are missed. When they're in place, positive changes happen. For John, this means he has now found something that works for him. His confidence is growing. He's met new people, and now exercise is becoming part of his everyday life, normal, not just an add-on. In the next episode, I'll be talking to someone with Parkinson's to hear their personal experience of peer support and its impact on them. And I will look at how existing long-term health condition support groups can be utilised to further develop physical activity peer networks. I hope you've enjoyed listening, and that you will tune in to the next podcast in this series, further exploring what community-based physical activity really looks like, how it fits into care pathways, and why it matters. Until then, I'll leave you with this one question. Do you want John's experience to be the exception or the norm?