john searle - exercise referral - time to improve the outcomes

Download John Searle - Exercise referral - time to improve the outcomes

Post on 18-Nov-2014



Health & Medicine

1 download

Embed Size (px)




  • 1. Exercise referral time to improve the outcome John Searle Chief Medical Officer FIA
  • 2. Exercise Exercise is the most effectivedisease prevention stuff there is
  • 3. Exercise in disease preventionHeart attacks Stroke
  • 4. Exercise in disease preventionObesity Type 2 diabetes
  • 5. Exercise in disease preventionDementia Stress
  • 6. Exercise in disease preventionDepression Falls
  • 7. Exercise in disease preventionVarious typesof cancer
  • 8. Exercise in disease management?
  • 9. Exercise in disease Improves symptoms Slows progression Promotes physical activity and wellbeing(British Journal of Sport and ExerciseMedicine 2009; 43: 550-555)
  • 10. Exercise referral schemes 1990s National Quality Assurance Framework 2001 BHFNC Toolkit 2010
  • 11. Do exercise referral schemeswork?NICE 2006there is insufficient evidence to recommendthe use of exercise referral services topromote physical activity other than part ifresearch studies where their effectivenesscan be evaluated
  • 12. HTA 2011 (in press)The National Institute of Health Research HealthTechnology Assessment AgencyLittle or no effect in increasing physical activity.Serious lack of properly controlled, randomisedstudies in exerciser referral.Many studies have a poor methodology
  • 13. Welsh National ExerciseReferral Scheme (2010) Higher levels of physical activity in patients with coronary risk factors Positive effects on depression and anxiety particularly in those referred wholly or partially for mental health reasons
  • 14. Why dont ER schemes work?Toolkit 2010 wide variation inInclusion / exclusion criteriaProgramme durationQualifications of instructorsAdherence to the NQAFScheme evaluation
  • 15. Other concernsLack of GP training Risk to patients
  • 16. Other concerns
  • 17. Joint Consultative Forum (JCF)
  • 18. Terminology Recommendation:Advising a patient to be more physicallyactive in order to improve their health andreduce the risk of disease
  • 19. Terminology exercise referralExercise referral is a formal process whichuses exercise as a component of themanagement of a patients condition, withthe objectives of improving or reducingthe rate of its progression andachieving an independent andsustainable increase in physical activity
  • 20. The processReferral of a patient by a health careprofessional to a service or an independentexercise referral instructor for the process ofproviding an exercise programme as part ofthe management of people (i) with stable orsignificant limitations related to a chronicdisease or disability and/or (ii) with one ormore CV disease risk factors
  • 21. Professional & operationalstandards in exercise referral Risk stratification Qualifications The process Record keeping Medico-legal issues Services and facilities
  • 22. Risk stratification thePAR-Q No to all the questions Heart rate < 100 bpm BP < 140/90Remain in the ER service, undertake a rangeof activities programmed by but notnecessarily supervised by the ER instructor
  • 23. Answers yes on the PAR-QIrwin Morgan assessment: Low risk as in PAR-Q no Medium risk personalised supervised programme High risk (i) cardiac into cardiac rehab programme (ii) non cardiac, multidisciplinary assessment before exercise
  • 24. Irwin Morgan assessment Not a validated tool but it is recommended in the Toolkit What else is there? ? PAR-Q + and PARMedEx in the future
  • 25. QualificationsFitness instructors working in exercise referral must be a REPs registered Exercise Referral Fitness Instructor or a REPs registered Level 4 Specialist Instructor, meeting the National Occupational Standards for the knowledge, competence, and skills of good practice.
  • 26. Assessment Personal details BMI Waist circumference Pre ex HR BP PA questionnaire - IPAQ Quality of life EQ-5D
  • 27. Assessment Aerobic not necessary ROM in musculoskeleta l disease Requested by referrer
  • 28. GoalsShort tern attendance, sessionalMedium term (i) condition specific(ii) Patient specificLong term asustainable increasein physical activity
  • 29. DeliveryACSM disease specificguidelinesAppropriateprogressionGood communicationTrust and rapport
  • 30. Monitoring Attendance During the session Repeat base line measurements at mid point and the end of the programme 6 and 12 months: physical activity and wellbeing questionnaires**using group sampling
  • 31. Exit strategies Absolutely essential! Keep in view from the outset What would the patient like to do to keep physically active? What is available? On-going support
  • 32. Medico-legal mattersDoctors must only refer patients for thepurposes of using exercise as part oftreatment to an appropriately qualified andregistered exercise referral fitness instructoror a service which employs such instructorsMedical Defence Societies
  • 33. Other matters Reporting to the referrer and to commissioners Service evaluation and appraisal by commissioners and professionally Instructor appraisal fit to practice
  • 34. Why the objectives? Provision of high quality, safe and effective exercise referral services Exercise becomes a routine part of the management of chronic disease Bench mark for commissioners
  • 35. How has it been done? JCF: drafting group + the Forum Advisory group from across the fitness sector Consultation process to mid August.(
  • 36. Help the bench mark is too high!
  • 37. Implementation will be gradual Standard setting Training institutions Operators Health professionals Commissioners NHS reforms timetable
  • 38. CHOICE Stay as we are and confirm the NICE judgment of 2006 and HTA 2010 OR Develop a modern professional service and provide long term benefits to patients