Charter to establish clinical exercise physiology as a recognised allied health profession in the UK: a call to action

A national survey of current rehabilitation service provisions for people living with chronic kidney disease in the UK: implications for policy and practice

BACKGROUND

National guidance recognises the key role of rehabilitation in improving outcomes for people living with chronic kidney disease. Implementation of this guidance is reliant upon an adequate and skilled rehabilitation workforce. Data relating to this is currently lacking within the UK. This survey aimed to identify variations and good practices in kidney physiotherapy (PT), occupational therapy (OT) and clinical exercise physiologist (CEP) provision; and to understand barriers to implementation.

METHODS

An online survey was sent to all 87 UK kidney units between June 2022 and January 2023. Data was collected on the provision of therapy services, barriers to service provision and responses to the COVID-19 pandemic. The quantitative survey was analysed using descriptive statistics. Free-text responses were explored using reflexive thematic analysis.

RESULTS

Forty-five units (52%) responded. Seventeen (38%) units reported having a PT and 15 (33%) an OT with a specialist kidney role; one unit (7%) had access to a CEP. Thirty units (67%) offered inpatient therapy services, ten (22%) outpatient therapy clinics, six (13%) intradialytic exercise, six (13%) symptom management and three (7%) outpatient rehabilitation. Qualitative data revealed lack of money/funding and time (both n = 35, 85% and n = 34, 83% respectively) were the main barriers to delivering kidney-specific therapy. Responders saw an increase in the complexity of their caseload, a reduction in staffing levels and consequently, service provision during the COVID-19 pandemic. Exemplars of innovative service delivery, including hybrid digital and remote services, were viewed as positive responses to the COVID-19 pandemic.

CONCLUSION

Despite clear evidence of the benefits of rehabilitation, across the UK, there remains limited and variable access to kidney-specific therapy services. Equitable access to kidney-specific rehabilitation services is urgently required to support people to 'live well' with kidney disease.

Establishment of clinical exercise physiology as a regulated healthcare profession in the UK: a progress report

In 2021, a 'call to action' was published to highlight the need for professional regulation of clinical exercise physiologists to be established within UK healthcare systems to ensure patient safety and align training and regulation with other health professions. This manuscript provides a progress report on the actions that Clinical Exercise Physiology UK (CEP-UK) has undertaken over the past 4 years, during which time clinical exercise physiologists have implemented regulation and gained formal recognition as healthcare professionals in the UK. An overview of the consultation process involved in creating a regulated health profession, notably the development of policies and procedures for both individual registration and institutional master's degree (MSc) accreditation is outlined. Additionally, the process for developing an industry-recognised scope of practice, a university MSc-level curriculum framework, the Academy for Healthcare Science Practitioner standards of proficiency and Continuing Professional Development opportunities is included. We outline the significant activities and milestones undertaken by CEP-UK and provide insight and clarity for other health professionals to understand the training and registration process for a clinical exercise physiologist in the UK. Finally, we include short, medium and long-term objectives for the future advocacy development of this workforce in the UK.

A multi-method exploration of a cardiac rehabilitation service delivered by registered Clinical Exercise Physiologists in the UK: key learnings for current and new services

BACKGROUND

Cardiac rehabilitation has been identified as having the most homogenous clinical exercise service structure in the United Kingdom (UK), but inconsistencies are evident in staff roles and qualifications within and across services. The recognition of Clinical Exercise Physiologists (CEPs) as a registered health professional in 2021 in the UK, provides a potential solution to standardise the cardiac rehabilitation workforce. This case study examined, in a purposefully selected cardiac exercise service that employed registered CEPs, (i) how staff knowledge, skills and competencies contribute to the provision of the service, (ii) how these components assist in creating effective service teams, and (iii) the existing challenges from staff and patient perspectives.

METHODS

A multi-method qualitative approach (inc., semi-structured interviews, observations, field notes and researcher reflections) was employed with the researcher immersed for 12-weeks within the service. The Consolidated Framework for Implementation Research was used as an overarching guide for data collection. Data derived from registered CEPs (n = 5), clinical nurse specialists (n = 2), dietitians (n = 1), service managers/leads (n = 2) and patients (n = 7) were thematically analysed.

RESULTS

Registered CEPs delivered innovative exercise prescription based on their training, continued professional development (CPD), academic qualifications and involvement in research studies as part of the service. Exposure to a wide multidisciplinary team (MDT) allowed skill and competency transfer in areas such as clinical assessments. Developing an effective behaviour change strategy was challenging with delivery of lifestyle information more effective during less formal conversations compared to timetabled education sessions.

CONCLUSIONS

Registered CEPs have the specialist knowledge and skills to undertake and implement the latest evidence-based exercise prescription in a cardiac rehabilitation setting. An MDT service structure enables a more effective team upskilling through shared peer experiences, observations and collaborative working between healthcare professionals.

Group-based exercise for Parkinson's: a qualitative study of participants and partners' perceptions of an exercise class delivered through a community-university collaboration

BACKGROUND

Community-based exercise programmes (CBEPs) offer a practical and viable approach to providing people with Parkinson's disease (PwP) the opportunity to exercise as an ancillary therapeutic benefit to pharmacological management. This study explores the perceptions of exercising participants (PwP) and non-participating partners involved in an exercise class delivered through a community-university partnership.

METHODS

Two separate focus group discussions were conducted: one with class participants (PwP: n = 7, H&Y scale I to III), and the other with non-participating partners of PwP (n = 4).

RESULTS

Thematic analysis of the data identified that a range of physical, psychological and social factors were perceived to influence engagement: (1) actively taking control, (2) exercise is medicine for the mind and body, and (3) a community working together to promote exercise for parkinson's. Participants and partners felt that the support from the group, including the instructors and student volunteers, empowered and supported PwP to proactively self-manage their health, enjoy exercise in an inclusive group setting, and develop strong social connections with others in the local Parkinson's community. Support to exercise from healthcare professionals was identified as both an enabler and barrier to participation.

CONCLUSIONS

This study underscores the significance of a community-university partnership as a complementary therapeutic approach for PwP. It also provides critical reflections on its sustainability, including implications for how exercise is considered as medicine for PwP. Additionally, it offers practical recommendations to galvanise community participation and provide inclusive and viable exercise opportunities for PwP.

Insights and recommendations into service model structure, staff roles and qualifications in a UK cancer specific clinical exercise service: a multi-method qualitative study

PURPOSE

Clinical exercise delivery in the United Kingdom is disparate in terms of service structure, staff roles and qualifications, therefore it is difficult to evaluate and compare across services. Our aim was to explore, in a purposely selected cancer exercise service that was recognised as effective; (i) how staff knowledge, skills and competencies contribute to the provision of the service, (ii) how these components assist in creating effective services, and (iii) to identify existing challenges from staff and service user perspectives.

METHODS

The Consolidated Framework for Implementation Research was used as an overarching guide to review the Prehab4Cancer service. Exercise specialists and service user perspectives were explored using a multi-method approach (online semi-structured interviews, online focus group and in-person observation) and data triangulation.

RESULTS

Exercise specialists were educated to a minimum of undergraduate degree level with extensive cancer-specific knowledge and skills, equivalent to that of a Registration Council for Exercise Physiologist (RCCP) Clinical Exercise Physiologist. Workplace experience was essential for exercise specialist development in behaviour change and communications skills.

CONCLUSIONS

Staff should be educated to a level comparable with the standards for registered RCCP Clinical Exercise Physiologists, which includes workplace experience to develop knowledge, skills and competencies in real-world settings.

Health policy considerations for combining exercise prescription into noncommunicable diseases treatment: a narrative literature review

Objectives

In this review, we aim to highlight the evidence base for the benefits of exercise in relation to the treatment of noncommunicable diseases (NCDs), draw on the Health Triangular Policy Framework to outline the principal facilitators and barriers for implementing exercise in health policy, and make concrete suggestions for action.

Methods

Literature review and framework analysis were conducted to deal with the research questions.

Results

Exercise prescription is a safe solution for noncommunicable diseases prevention and treatment that enables physicians to provide and instruct patients how to apply exercise as an important aspect of disease treatment and management. Combining exercise prescription within routine care, in inpatient and outpatient settings, will improve patients' life quality and fitness levels.

Conclusion

Inserting exercise prescription into the healthcare system would improve population health status and healthy lifestyles. The suggestions outlined in this study need combined efforts from the medical profession, governments, and policymakers to facilitate practice into reality in the healthcare arena.

Understanding the role of allied health professional support workers with exercise qualifications in the delivery of the NHS Long Term Plan within allied health professional services in England

Demand modelling for the allied health professionals (AHPs) workforce showed that significant expansion would be needed to successfully deliver on the National Health Service (NHS) Long Term Plan. The aim was to explore the use of AHP support workers with exercise qualifications in AHP services and to understand their current and potential role in NHS commissioned AHP services in England. The project had two phases and took place between October 2020 and January 2021. In phase one, an electronic survey was carried out to identify the scope and variation of exercise professionals working in AHP support roles in NHS commissioned services. Semi-structured interviews were conducted in phase two to gain further understanding about the experiences of those involved in AHP commissioned services. Survey data were analysed using descriptive statistics and interview data were qualitatively analysed using thematic analysis. Recorded interviews were transcribed and initially coded. Coding was then refined and themes were identified. Support workers with exercise qualifications made a valued contribution to AHP services and were considered cost-effective in delivering a specialised exercise intervention. AHP support workers contributed to a range of tasks relating to clinical exercise prescription. Collated data highlighted inconsistency in the way AHP support workers with exercise qualifications identified themselves, despite similar roles. Variation existed in the level of autonomy for AHP support workers with exercise qualifications, even within the same NHS Agenda for Change band. Attempts to manage this disparity involved numerous governance processes to ensure safe, high-quality healthcare in the context of delegation to support workers. Limited training and development opportunities and the lack of career progression for support workers were consistently acknowledged as a source of frustration and hindrance to individuals fulfilling their potential. AHP support workers with exercise qualifications have potential to positively impact service delivery providing added value to the NHS workforce.

Survey of exercise testing and training in cystic fibrosis clinics in the UK: a decade of progress

OBJECTIVES

Regular exercise testing is recommended for people with cystic fibrosis (pwCF), as is the provision and regular review of exercise training programmes. A previous survey on exercise testing and training for pwCF in the UK was conducted over a decade ago. With the landscape of CF changing considerably during this time, this survey aimed to evaluate UK-based exercise testing and training practices for pwCF a decade on.

DESIGN

Cross-sectional, online survey.

PARTICIPANTS

A survey was distributed electronically to UK CF clinics and completed by the individual primarily responsible for exercise services. Descriptive statistics and qualitative analyses were undertaken.

RESULTS

In total, 31 CF centres participated, representing ~50% of UK specialist clinics. Of these, 94% reported using exercise testing, 48% of which primarily use cardiopulmonary exercise testing. Exercise testing mostly occurs at annual review (93%) and is most often conducted by physiotherapists (62%). A wide variation in protocols, exercise modalities, normative reference values and cut-offs for exercise-induced desaturation are currently used. All centres reportedly discuss exercise training with pwCF; 94% at every clinic appointment. However, only 52% of centres reportedly use exercise testing to inform individualised exercise training. Physiotherapists typically lead discussions around exercise training (74%).

CONCLUSIONS

These data demonstrate that the majority of respondent centres in the UK now offer some exercise testing and training advice for pwCF, representing a marked improvement over the past decade. However, continued efforts are now needed to standardise exercise practices, particularly regarding field testing practices and the translation of test results into personalised training programmes for pwCF.

Is healthcare a team sport? Widening our lens on interprofessional collaboration and education in sport and exercise medicine

Effective interprofessional collaboration (IPC) has great potential to improve healthcare delivery. Therefore, students and trainees in healthcare professions should be prepared for a collaborative workforce through interprofessional education (IPE) settings. However, IPC and IPE are rarely addressed in sport and exercise medicine (SEM), although the field significantly impacts the healthcare system. Hence, we conducted a webinar to promote IPC and IPE in the Swiss SEM community. The lessons resulting from the webinar were: (1) professions involved in SEM should have opportunities to learn, with, from and about other professions in healthcare to achieve mutual respect and understanding; (2) IPC and IPE in SEM may raise awareness, value and recognition of the contributions by exercise scientists in healthcare; (3) IPC and IPE may consider collaborating with a variety of professions not traditionally integrated into healthcare but involved in broader public health and physical activity promotion. In summary, sports and exercise professions should embrace interprofessional approaches to better realise their contribution to healthcare and public health.

Developing an ecological approach to physical activity promotion in adults with Cystic fibrosis

BACKGROUND

There are few examples of interventions designed to promote physical activity (PA) in adults with Cystic fibrosis (CF). Increasing levels of habitual PA may be more feasible and result in greater compliance than conventional exercise training inventions which give little or no attention to long-term PA behaviour. Despite this there is limited research exploring perceptions of PA among adults with CF. The study aimed to understand the ecological correlates of PA in adults with CF and to involve individuals with CF, their families (where applicable) and clinicians in a formative process to inform the development of an ecological approach to PA promotion in this population.

METHODS

An iterative approach was utilised, whereby findings from earlier phases of the research informed subsequent phases. Semi-structured interviews were conducted to explore patients' perceptions of PA, devised using the PRECEDE component of the PRECEDE-PROCEED model. Followed by, focus groups to discuss the perceived barriers, facilitators and opportunities for PA participation and how this information could inform the development and delivery of a PA intervention. Separate focus groups were conducted with individuals with CF (n = 11) and their families and CF MDT members. Thematic analysis was used to construct themes.

RESULTS

Physical and mental wellbeing manifested as both barriers and facilitators of PA. CF is characterised by a progressive decline in physical function, which presents as a number of challenging symptoms and set-backs for an individual with CF. PA represents an opportunity for participants to slow the rate of this decline and manage the symptoms associated with the condition. Enjoyment was an important facilitator of PA. Exercise professionals and family reinforce PA behaviour, particularly during adolescence.

CONCLUSIONS

PA promotion should form part of routine CF care with additional exercise professional support during adolescence.

Exercise Science Graduates in the Healthcare System: A Comparison Between Australia and Switzerland

Physical inactivity (PI) is a leading risk factor for global mortality worldwide, a major preventable cause of non-communicable diseases (NCDs) and a socioeconomic burden for healthcare systems. Fortunately, evidence shows that exercise interventions delivered by qualified exercise science graduates is an effective way to reduce PI, prevent and treat NCDs. This study compares the integration of exercise science graduates, defined as university graduates with degrees in sport and exercise science, in the healthcare systems of Australia, a commonly cited model in this regard, and Switzerland, a country considered to have an effective but costly healthcare system. For both countries, three domains were reviewed: healthcare system, exercise science graduates' education, and roles played by exercise science graduates in healthcare system. Australia formally recognizes specifically trained exercise science graduates (referred to as Accredited Exercise Physiologists) as healthcare professionals. The exercise interventions they deliver, which were shown to be cost-effective and lead to positive health outcomes, are covered by Medicare, the Australian universal health insurance. However, Medicare covers only a maximum of 5 yearly sessions of all allied-health services taken together. Conversely, Switzerland, despite offering university master's degrees that focus on physical activity delivery to clinical populations, does not recognize the respective graduates as healthcare providers. As a result, their services are not covered by the Swiss health insurances. The latter do, however, cover a generous number of services (not formally limited) delivered by other allied-health professionals. In conclusion, Australia makes a better use of exercise science graduates than Switzerland does. Switzerland would benefit from establishing a clinical profession for exercise science graduates, defining competencies that they should acquire and setting their scope of practice. The very restricted number of therapy sessions covered by Medicare might limit the positive impact exercise science graduates have on the Australian healthcare system. Overall, mutual learning between countries can promote development and global recognition of clinical positions for exercise science graduates.

Clinical exercise provision in the UK: comparison of staff job titles, roles and qualifications across five specialised exercise services

Objectives

In the UK, the National Health Service long-term plan advocates exercise as a key component of clinical services, but there is no clearly defined workforce to deliver the plan. We aimed to provide an overview of current UK clinical exercise services, focusing on exercise staff job titles, roles and qualifications across cardiovascular, respiratory, stroke, falls and cancer services.

Methods

Clinical exercise services were identified electronically between May 2020 and September 2020 using publicly available information from clinical commissioning groups, national health boards and published audit data. Data relating to staff job titles, roles, qualifications and exercise delivery were collected via electronic records and telephone/email contact with service providers.

Results

Data were obtained for 731 of 890 eligible clinical services (216 cardiac, 162 respiratory, 129 stroke, 117 falls, 107 cancer). Cardiac rehabilitation services provided both clinical (phase III) and community (phase IV) exercise interventions delivered by physiotherapists, exercise physiologists (exercise specific BSc/MSc) and exercise instructors (vocationally qualified with or without BSc/MSc). Respiratory, stroke and falls services provided a clinical exercise intervention only, mostly delivered by physiotherapists and occupational therapists. Cancer services provided a community exercise service only, delivered by vocationally qualified exercise instructors. Job titles of ‘exercise physiologists’ (n=115) bore little alignment to their qualifications, with a large heterogeneity across services.

Conclusion

In the UK, clinical exercise services job titles, roles and qualifications were inconsistent. Regulation of exercise job titles and roles is required to remove the current disparities in this area.