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The changing landscape of exercise referral

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21 October 2013

Amanda Cheesley, the Long Term Conditions Advisor Royal College of Nursing outlines the opportunities arising from an array of public health reforms

Since 2010 the Joint Consultative Forum's focus and efforts have been dominated by one task: developing new Professional and Operational Standards for Exercise Referral.
Since we started this project in 2010 there have been several notable developments:

  • NICE announced the inclusion of physical activity within the Quality and Outcomes Framework for GP's
  • The evidence base for physical activity and exercise referral was assessed by Dr. Tobey Pavey in a review which correctly asserted that there is a "weak evidence base for exercise referral programmes" in their current guise
  • The Royal College of Physicians published "Exercise for Life" in which it called for a national strategy for physical activity, QOF incentives for activity interventions, and the development of Primary Care Information systems that could support the risk stratification of patients and the identify appropriate care pathways
  • The evidence base for physical activity counselling interventions, in improving levels of physical activity amongst sedentary individuals, is now widely acknowledged
  • Sport and Exercise Medicine Consultants now exist to advise and support exercise programmes for the prevention and management of disease

These developments have somewhat "moved the goalposts" regarding the development of Professional and Operational Standards for Exercise Referral, whilst re-iterating the need for an edifying set of easy to use standards.

The document is currently passing through the respective councils and decision making groups of the various Royal Colleges, so there are still likely to be some adjustments. Nonetheless, the Standards include several notable highlights that providers should take note of.

Firstly, exercise referral has been defined "as the referral of a patient by a healthcare professional to a service for the purpose of providing exercise as part of the management of people with stable and/or significant functional impairment/limitations related to a chronic disease or disability and/or one or more significant cardiovascular disease risk factors". Importantly, "service" could mean a publicly funded or privately operated referral programme which may take place within a gym, leisure centre, health centre or at some other community location.

Secondly, the Standards have acknowledged that numerous professionals are involved in the delivery of exercise referral. It is no longer the referral of a patient from a General Practitioner to an Exercise Referral Qualified Professional, rather the Standards acknowledge the role of allied healthcare professionals such as Physiotherapists, SEM Consultants, Occupational Therapists, Nurses and GPs in generating referrals.

Thirdly, the Standards have developed a new approach to analysing risk whereby the risk stratification process must state an individual patient's overall risk of "experiencing an acute/adverse event during exercise, or of their disease progressing". The risk stratification will commence with an initial screening tool in order to identify "inappropriate referrals", followed by a risk classification process, which will categorise patients into low, medium or high risk, and the risk will be continuously assessed throughout the programme.

Low risk patients will remain within the referral programme but can actually undertake a wide range of activities provided that the programming, monitoring and supervision of each patient's safety, performance and progress is undertaken. Medium risk patients will be entered into an individualised supervised exercise programme. High risk cardiac patients must be referred to a Cardiac Rehabilitation Service whilst non-cardiac patients identified as high risk should be referred to a Multi-Disciplinary Team.

Under these Standards referral programmes should extend beyond the four walls of a facility into a community.

The Standards should also ensure that patients receive a tailored programme that offers the best chance of generating sustainable and independent activity. For example, a patient with Type 2 Diabetes controlled by diet, could potentially find themselves meeting with a Register of Exercise Professionals (REP'S) Level 3 Exercise Referral Registered Professional once a fortnight, whilst undertaking a wide range of activities such as a dance class or walking group during the intervening period.

The ultimate aim of an exercise programme is to place a patient on a path to independent, realistic and sustainable exercise and the Standards should put in place a framework for every patient to meet this goal.

Amanda Cheesley is the Long Term Conditions Advisor at the Royal College of Nursing

Read Together: summer 2013

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