Community based exercise referral
“GP training is a crucial link between GP practices and community based Exercise Referral Schemes.” Says FSEM (UK) Lay Adviser Jason Feavers.
Whereas many fitness instructors come from a sports or gym training background, my introduction to fitness was very much around exercising for health benefits. Working long hours as a corporate insurance broker, I did not feel I had time to exercise but was forced to make time as stress and health issues started to affect my life. After feeling significant benefits from a combination of swimming, running and gym exercises, I decided to quit a fairly well paid job and train as a fitness instructor. I soon got involved in Exercise Referral, and this has been my main work for the past 14 years.
Exercise Referral is defined as “The referral of a patient by a health professional to a facility (public or privately operated, or individual physical activity referral instructor) for the purpose of providing a physical activity programme as part of the management of people with stable, or significant limitations related to chronic disease, or disability and/ or one or more significant cardiovascular disease risk factors” (Professional and Operational Standards for Exercise Referral 2011).
I co-ordinate the Exercise Referral scheme for City of York council. A significant part of the York scheme is provision of condition specific exercise classes. There is a long established pathway between clinical led Phase 3 Cardiac rehabilitation programmes and fitness instructor led Phase 4 programmes.
Within the York scheme we also have similar pathways for respiratory conditions, long term neurological conditions and cancer. The majority of referrals for these conditions come from secondary care, either through physiotherapists or specialist nurses. I believe these type of classes will play an increasing role in future healthcare provision, as a way of reducing the cost of hospital admissions to the NHS and reducing Adult Social Care costs by increasing and maintaining independence for people with long term conditions.
Whilst Exercise Referral was traditionally based on a GP referring into a gym setting, another key aspect of the York scheme is the range of exercise modalities which are available. Only 10% of general populations regularly exercise in a gym and yet people seemed surprised when retention rates weren’t particularly good for gym based Exercise Referral. Changes to Exercise Referral qualifications allows instructors with a background in modalities such as aqua, circuits and, my preferred option outdoor exercise such as Nordic walking, to deliver Exercise Referral within those settings. I’ve worked closely with Nordic Walking UK over the past few years to develop and deliver an accredited Exercise Referral course specifically based around Nordic walking. This is proving an extremely popular choice of activity within the York scheme with high retention rates and we deliver specific classes for breast cancer, Parkinson’s disease and musculoskeletal conditions.
Another aspect of the York scheme, which I believe will play an increasing role in the future, is a recommendation option or signposting into general physical activity programmes such as health walks, cycling and swimming programmes.
This is aimed at patients that are not requiring specific programming for medical conditions. Exercise Referral instructors are trained to deliver an evidence based programme and have an understanding of the medical conditions covered within Exercise Referral, exercise considerations for medical conditions and effects of medications on exercise. We also use the signposting pathways as an exit strategy from Exercise Referral classes or to enable participants to access additional ways to become more active.
To break down barriers we have specific programmes such as ‘Welcome back to the Pool” which incorporates an initial consultation and meet and greet with a course of six swimming lessons. This has proved particularly successful for people with mobility issues, neurological conditions and mental health conditions. It helps with confidence as well as support to overcome barriers such as access to the pool or adapting swimming technique. It also has a social aspect and encourages participants to continue to access the pool after the six weeks along with other class participants.
Many physical activity opportunities are led by volunteer leaders or instructors who do not have the knowledge to adapt exercise to take account of medical conditions. The British Heart Foundation’s Exercise Referral Toolkit states it “should be noted that recommending or sign-posting patients to local physical activity opportunities such as lay-led walking schemes is quite distinct from referring an individual to a dedicated service and transferring relevant medical information about this individual to this service.”
A draft update to the NICE 2006 review of Exercise Referral schemes, due to be published in full in September 2014, says that “the Department of Health urges commissioners, practitioners and policy makers to continue to provide high quality exercise referral schemes for their local population, where these address the medical management of conditions, e.g. type 2 diabetes, obesity and osteoporosis”. The update also suggests that Exercise Referral schemes should not be commissioned as a cost effective way to increase physical activity levels, though in my opinion that somewhat misses the point as to the purpose of Exercise Referral.
I believe the future of Exercise Referral will be very dependent on offering high quality programmes that are evaluated and proven to be cost effective. Rather than trying to evaluate an overall scheme, evaluating condition specific programmes makes it much easier to calculate return on investment.
GPs having a better understanding of specific exercise for management and treatment of medical conditions, rather than just a knowledge that physical activity is beneficial for health, will be crucial for better take up of schemes.
I’m delighted to be working with the Faculty of Sport and Exercise Medicine as a Lay Adviser. Including SEM training within undergraduate medical training will be an important step as will any progression towards more SEM consultants within the NHS. In the same way that Public Health Consultants are an integral part of Local Authorities statutory duty to improve public health, I believe an SEM consultant should be an integral part of every Clinical Commissioning Groups (CCGs).
In the short term I would hope that more GPs take up post graduate training in SEM and I see this as a crucial link between GP practices and community based exercise referral schemes, particularly where work is undertaken to look at reductions in non-routine GP appointments, hospital admissions and medication costs.
Follow Jason on Twitter @jasonfeavers
Jason is a lead tutor for Nordic Walking UK having developed an accredited Exercise Referral course based around Nordic Walking and specific programmes incorporating resistance exercise, balance, coordination and relaxation exercises with Nordic Walking, which can be programmed for conditions including breast cancer, Parkinson’s disease and musculoskeletal conditions.
Website for City of York council’s HEAL (Health Exercise Activity Lifestyle) programme www.york.gov.uk/heal
Website for Nordic Walking UK www.nordicwalking.co.uk
Faculty of Sport and Exercise Medicine information on exercise medicine for CCGs – A Fresh Approach in Practice