1. Exercise referral – time to
improve the outcome
John Searle
Chief Medical Officer FIA

2. Exercise
Exercise is the most effective
disease prevention ‘stuff’ there
is

3. Exercise in disease
prevention
Heart attacks Stroke

4. Exercise in disease
prevention
Obesity Type 2 diabetes

5. Exercise in disease
prevention
Dementia Stress

6. Exercise in disease
prevention
Depression Falls

7. Exercise in disease
prevention
Various types
of cancer

8. Exercise in disease
management?

9. Exercise in disease
• Improves symptoms
• Slows progression
• Promotes physical activity and wellbeing
(British Journal of Sport and Exercise
Medicine 2009; 43: 550-555)

10. Exercise referral schemes
• 1990’s
• National Quality Assurance Framework
2001
• BHFNC Toolkit 2010

11. Do exercise referral schemes
work?
NICE 2006
‘there is insufficient evidence to recommend
the use of exercise referral services to
promote physical activity other than part if
research studies where their effectiveness
can be evaluated’

12. HTA 2011 (in press)
The National Institute of Health Research Health
Technology Assessment Agency
Little or no effect in increasing physical activity.
Serious lack of properly controlled, randomised
studies in exerciser referral.
Many studies have a poor methodology

13. Welsh National Exercise
Referral 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 don’t ER schemes work?
Toolkit 2010 – wide variation in
•Inclusion / exclusion criteria
•Programme duration
•Qualifications of instructors
•Adherence to the NQAF
•Scheme evaluation

15. Other concerns
Lack of GP training Risk to patients

16. Other concerns

17. Joint Consultative Forum (JCF)

18. Terminology
• Recommendation:
Advising a patient to be more physically
active in order to improve their health and
reduce the risk of disease

19. Terminology – exercise referral
Exercise referral is a formal process which
uses exercise as a component of the
management of a patient’s condition, with
the objectives of improving or reducing
the rate of its progression and
achieving an independent and
sustainable increase in physical activity

20. The process
Referral of a patient by a health care
professional to a service or an independent
exercise referral instructor for the process of
providing an exercise programme as part of
the management of people (i) with stable or
significant limitations related to a chronic
disease or disability and/or (ii) with one or
more CV disease risk factors

21. Professional & operational
standards in exercise referral
• Risk stratification
• Qualifications
• The process
• Record keeping
• Medico-legal issues
• Services and facilities

22. Risk stratification – the
PAR-Q
• ‘No’ to all the questions
• Heart rate < 100 bpm
• BP < 140/90
Remain in the ER service, undertake a range
of activities programmed by but not
necessarily supervised by the ER instructor

23. Answers ‘yes’ on the PAR-Q
Irwin 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. Qualifications
Fitness 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. Goals
Short tern –
attendance, sessional
Medium term
(i) condition specific
(ii) Patient specific
Long term – a
sustainable increase
in physical activity

29. Delivery
ACSM disease specific
guidelines
Appropriate
progression
Good communication
Trust 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 matters
Doctors must only refer patients for the
purposes of using exercise as part of
treatment to an appropriately qualified and
registered exercise referral fitness instructor
or a service which employs such instructors
Medical 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.
(stephen.wilson@fia.org.uk)

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