House of Lords - Sport and exercise science and medicine: building on the Olympic legacy to improve the nation's health

Sport and exercise science and medicine: building on the Olympic legacy to improve the nation's health - Science and Technology Committee Contents

CHAPTER 3: Translation of findings to public health benefits

32. In this chapter we consider the translation of findings from SES and SEM research to public health benefits, barriers to translation and possible solutions. By "translation", we mean the informing of health care provision and Government policy by the findings of this research.

Ongoing translation work

33. Both DH and the NHS have made efforts to promote the public health benefits of exercise.[67]

PHYSICAL ACTIVITY GUIDELINES

34. The Chief Medical Officers' Physical Activity Guidelines recommend, for example, 150 minutes of moderate intensity exercise (such as brisk walking or mowing the lawn) or 75 minutes of vigorous activity (such as swimming or aerobic dancing) (or a combination of the two) a week for 19-64 year old adults, and make other specific recommendations to children and young people, under fives and those over 65. We note, however, that although these recommendations have been published, there is no strategy for ensuring that the population, or even medical professionals, are aware of them.[68]

SEM SPECIALISTS

35. The first cadre of SEM specialists are currently being trained—thereby fulfilling one of the Government commitments in the London 2012 Olympic bid.[69] There is some uncertainty about how many posts will be available for them to fill, and there is a risk they will leave the NHS to work in the private sector.[70] But, although the NHS needs to articulate the expected career route for these specialists, we see the development of this speciality as a positive step.

EXERCISE REFERRAL

36. Primary care exercise interventions have been developed.[71] DH contend that these short-term exercise interventions have been used to some effect by GPs.[72] The services were commissioned following an evaluation by the National Institute for Health and Clinical Excellence (NICE) which demonstrated that short interventions offer value for money.[73] However, the evidence we received suggested that there is significant scope for greater use of physical activity as a treatment and preventative measure. Sport England, for example, argued that exercise prescription should "sit alongside" pharmaceutical and surgical interventions. They made the case for a "cultural change ... to improve national physical activity levels" which "should be led by the NHS".[74] Intelligent Health argued that exercise referral provision was "patchy" and highlighted concerns from London-based GPs about a lack of feedback from interventions, and time delays in patients being seen.[75] NHS London's campaign, My Best Move, includes the commissioning of exercise guidance for specific chronic conditions for GPs to refer to in consultations, similar in format to medication reference guides.[76]

BEACON SEM SERVICES

37. Pathway clinical commissioning groups (which will be responsible for commissioning services in the reformed health care system) in Sheffield are using "beacon" SEM services to explore further the benefits of SEM services in primary care.[77]

Barriers to translation

38. We have identified several barriers to the translation of findings from sport and exercise research to public health benefits, aside from the primary barrier of quality of research, which we considered in Chapter 2.

FUNDING FOR TRANSLATIONAL RESEARCH

39. The National Institute for Health Research (NIHR) has responsibility for funding public health research and "research for patient benefit",[78] although some translational funding is provided by charities such as Arthritis Research UK.[79] Lack of funding for translational research and the absence of incentives for private sector funding, were highlighted to us as barriers to translation.[80] Professor Patterson, for example, regretted the absence of sufficient funding, particularly for SEM research.[81] Professor McConnell, MOD, The Physiological Society and RCP all observed that there was little financial incentive for pharmaceutical companies to fund this research.[82] Given the estimated costs of inactivity (see paragraph 3 above), and the potential benefits of the use of exercise as a preventative measure and treatment for chronic diseases, we recommend that the NIHR and other research funders should stimulate research to translate findings of sport and exercise science and medicine to public health benefits.

TRAINING FOR HEALTH PROFESSIONALS

40. Institutional barriers within the healthcare system are also preventing translation of research into treatments. Professor Hugh Montgomery, Professor of Intensive Care Medicine and Director, UCL Institute for Human Health and Performance, and seminar participants told us that SEM was not adequately covered in medical training.[83] Anne Milton MP, Minister for Public Health, DH, agreed that there was a need for training for health professionals.[84] Training was also recommended by Arthritis Research UK, Professor McConnell, Professor Vrbova and The Physiological Society.[85] When delivering training in 48 GP practices in 28 London Boroughs, Intelligent Health found that none of the London GPs to whom they presented were aware of the latest Physical Activity Guidelines.[86]

41. It was suggested in our second seminar (on the Olympic public health legacy) that adding physical activity to the GP Quality and Outcomes Framework (QOF), a voluntary incentive scheme for GP practices in the UK which rewards them for "how well they care for patients",[87] would incentivise GPs to increase their knowledge of SEM.[88] Sport England agreed that adding physical activity to the QOF would raise the profile of physical activity,[89] and Intelligent Health also called for its inclusion.[90]

42. Inappropriately prescribed exercise can give rise to significant risks to patient health—for example, certain osteoarthritic conditions can be exacerbated by the wrong forms of exercise—which underlines the importance of adequate training being provided. Colonel Etherington argued that improved information would assist GPs to prescribe exercise.[91] We agree. We recommend that the NHS, medical schools, the General Medical Council and relevant professional bodies ensure that appropriate training, both at undergraduate level and in continuing professional development opportunities, is available for health professionals to support the prescription of exercise as a preventative measure and treatment, where science supports this. We invite the NHS to consider adding physical activity to the QOF.

GUIDANCE

43. As well as adequate training, suitable guidance is needed to support health professionals in prescribing exercise.[92] At present, NICE guidelines to support GPs in the treatment of chronic diseases, such as diabetes and heart disease, do not recommend specific types of exercise.[93] We note, however, that NHS London has commissioned Intelligent Health to produce a book on exercise treatment for specific diseases.[94] It would appear, therefore, that there is sufficient scientific evidence to justify NICE reviewing their guidelines for chronic diseases and to improve their guidance about use of exercise as a treatment. We recommend that NICE assess the quality of research to support the prescription of specific exercises in the management of chronic diseases and, where the evidence supports it, update their guidelines to reflect these findings.

QUALITY ASSURANCE OF EXERCISE PROFESSIONALS

44. The Register of Exercise Professionals (REP) is a scheme to set standards for qualifications and continuing professional development of exercise professionals.[95] It is a voluntary scheme and some witnesses raised concerns about the lack of compulsory professional standards for exercise therapists. The MOD contrasted the absence of high quality training and assurance for civilian exercise therapists with the extensive training given to Exercise Rehabilitation Instructors in the military.[96] RCP suggested that this lack of assurance did not instil confidence and, as a result, GPs were wary of using exercise referral schemes.[97] The British Association of Sport and Exercise Sciences (BASES), similarly, highlighted the absence of a professional registration system for exercise professionals recognised by the NHS.[98] Anne Milton MP was unconvincing in her reply when asked about formalising regulation, simply saying: "we are not very fond of statutory regulation".[99] We were, however, more convinced by her view that "if exercise is used as prescription it is important that, if we are spending public money, we [the Government] are assured that it is well spent and spent by people who have reached an appropriate standard and are achieving a certain quality of service".[100] We recommend that the NHS and NICE evaluate the most effective mechanism for assuring the quality of service delivered by exercise professionals in exercise referral schemes.

GOVERNMENT POLICY

45. The final barrier to translation which we have identified are weaknesses in the Government's approach to promoting physical activity, exercise and sport. There is some cross-departmental work to promote physical activity. For example, DH work with the Department for Transport to promote active travel policy, including walking and cycling.[101] They also work with the Department for Education to promote physical activity in schools.[102] We consider the existence of a Cabinet Sub-Committee on public health to be a positive first step towards joined-up policy,[103] although we did not receive any evidence as to its effectiveness.

46. Despite these positive examples, the Sport and Recreation Alliance argued that there was scope for better integration of sports, health and physical activity policies.[104] The RCP agreed and argued that "sport, health and exercise medicine are interlinked and a positive message of their benefit should be given".[105] The 2010-11 Active People Survey by Sport England suggested that participation in sport was no longer increasing.[106] Whilst we have excluded behaviour change from the scope of this report, we would observe that these figures suggest that the Government need to do more to promote physical activity (of which sport is one form). This will require a joined-up approach between departments, and also with local authorities (since local authority Health and Wellbeing Boards will help promote public health under the revised health care system).

47. We were disappointed by the assertion of the Minister, Hugh Robertson MP, that DCMS should not help promote physical activity through sport. He also said: "the baseline for ... the whole sport plans, is driving up participation in sport; it is not a bigger drive on the nation's health".[107] This is at odds with the statement made by Dame Tessa Jowell MP about the Olympic legacy (see paragraph 3 above).[108] Whilst we understand that DCMS had to adjust its sport participation targets, to which reference was made in a National Audit Office report,[109] this does not justify separating sports participation from the physical activity and health agendas. We were further surprised that neither DCMS nor DH could point to policy lessons learnt from international examples.[110] Mr Robertson suggested that the Australian Institute of Sport (AIS) was following the example of the English Institute of Sport's (EIS), and yet the AIS have developed a National Sport Science Quality Assurance Programme "to promote continuous improvement in sports science testing standards in Australia and to help sports science programmes involved in the assessment of athletes to establish and maintain an environment of national standard",[111] from which UK Sport (who own EIS) could learn. We find it remarkable that DCMS is not concerned with the health benefits of sport (as a form of physical activity). We recommend that the Government take a strong, joined-up approach to promoting the health benefits of exercise and physical activity, and that DCMS play an active part in this. We also recommend that the Government look to international models for improving the quality and application of sport science.

National Centre for Sport and Exercise Medicine

48. A £30 million capital grant has been given to three consortia to develop the NCSEM.[112] Mike Farrar, Government champion for sport and physical activity and Chief Executive of the NHS Confederation, and Anne Milton MP indicated that the Centre would have to bid for future funding. Many witnesses found this unsatisfactory.[113] The RCP were unsure of the strategic intent of the NCSEM and identified a "risk of disconnect" between the sport medicine and sport science communities, and of the money supporting existing local research rather than a national strategy.[114] Professor Montgomery summed up the current situation as follows: "the money has been put in for infrastructure, but that is not posts or research grants; it is floor space".[115] Given the level of seed investment made, and the importance of this research, the proposed strategy is unsatisfactory. We recommend that DH clarifies the intended role of the NCSEM and outlines how it will ensure that the work of the Centre will be sustainable.

Research Council funding

49. The Research Councils fund some research in SES and SEM.[116] For example, the Biotechnology and Biological Sciences Research Council (BBSRC) have two calls for research proposals jointly sponsored by UK Sport which are targeted specifically at understanding and improving elite athlete performance: 'High Performance Sport as a Model for Biological Research', and 'High Performance Sport as a model for the acquisition, retention and retraining of an individual's skill base'.[117] The Medical Research Council's (MRC) research priorities include understanding the roles of physical activity and sedentary behaviour in the maintenance of health and also the prevention of disease.[118] The Engineering and Physical Sciences Research Council have also funded research into use of sensors to improve athletic performance.[119] However, RCP, MOD, Professor McConnell and The Physiological Society expressed concern that there was no lead research council,[120] and the area might fall between BBSRC and MRC.[121] For example, The Physiological Society criticised the lack of integrative human physiologists on funding boards.[122] However, in the light of our finding that there is limited high quality research in these fields it is unsurprising that they do not fund more SES and SEM research. The NCSEM, sports scientists and sport medical professionals must demonstrate that they can undertake research of the same quality as fundamental disciplines and that they have the institutional support to carry it out. We recommend that the Research Councils, particularly BBSRC and MRC, demonstrate that they are co-operating to ensure that good quality research in SES and SEM does not fall between the two councils.

Absence of co-operation and co-ordination

50. We heard significant concerns about the absence of co-ordination and limited co-operation in the fields of SES and SEM. Professor Jones, Professor McConnell, MOD, Professor Mullineaux, RCP and The Physiological Society were critical of the absence of co-ordination.[123] Professor McConnell described SES as "rudderless".[124] The Physiological Society said that there was a lack of incentives for clinicians and researchers to work together,[125] and the lack of co-operation was confirmed by RCP, MOD and Professor Jones.[126] The Physiological Society concluded that "there is a strong sense that far more organisation and co-ordination across sport-sciences centres is required, in order to deliver high quality data".[127] The need for co-ordination and co-operation was a key theme in evidence. As the NIHR promotes research of benefit to patients and the public, and is recognised for its collaborative approach, they are well placed to promote this co-ordination and co-operation.[128] Given the importance of co-ordination and co-operation to further this field, we recommend that the NCSEM lead the development of a National Sports and Exercise Science and Medicine strategy. Such a strategy would seek to engage researchers and clinicians (both from within and outside the Centre) to identify key research needs, improve the quality of research, promote collaboration and co-ordinate research in SES and SEM over the next five years. The Centre should consider the work of international counterparts, to learn from their experiences.

51. Furthermore, the expertise of MRC, BBSRC, NIHR, UK Sport, charities, researchers and clinicians in these fields must be shared to facilitate cross-fertilisation of ideas, and to ensure that the lessons of good science applied to elite and non-elite athletes are translated into public health benefits. We recommend that the NIHR provide a lead to this work.

67 DH. Back

68 Op. cit. Start Active, Stay Active. Back

69 DH. Back

70 QQ 19-20. Back

71 NHS: Let's Get Moving-A new physical activity care pathway for the NHS. Commissioning Guidance, 2009. Back

72 DH. Back

73 NICE: Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling, 2006. Back

74 Sport England. Back

75 Intelligent Health. Back

76 DH, Intelligent Health. Back

77 DH. Back

78 http://www.nihr.ac.uk/research/Pages/default.aspx. Back