Leave the clinical to the clinicians

The Leisure Review’s health correspondent, the Commissioner, considers the origins of the promotion of physical activity and wonders whether exercise professionals have the right to decide who will and will not take part.

Who is most qualified to measure the impact of exercise on the public?

The scientific evidence is compelling. Physical activity not only contributes to well-being, but is also essential for good health. People who are physically active reduce their risk of developing major chronic diseases – such as coronary heart disease, stroke and type 2 diabetes – by up to 50%, and the risk of premature death by about 20-30%.
Chief Medical Officer, April 2004.

It’s been nearly 10 years since ‘at least five times a week’ was published. So why is it that I see a continuous reinvention of this evidence? And why has it taken part of the sector’s leadership nearly 10 years to wake up to the evidence this document presented?

I think many of us who work within the physical activity sector have known for ever that being active improves health. You only have to look at the smiles on people’s faces to know that something good is happening when they are active. Does it really take evidence to prove that the most basic of human functions is beneficial?

Humankind has evolved to move. This fundamental movement is associated with the ‘fight or flight’ theory. The fight-or-flight response (also called the fight-or-flight-or-freeze response, hyperarousal or the acute stress response). It is a physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival. It was first described by Walter Bradford Cannon in 1932 and it may be interesting to note that Walter Bradford Cannon also popularised the concept of homeostasis.

All parts of the body which have a function, if used in moderation and exercised in labours in which each is accustomed, become thereby healthy, well developed and age more slowly, but if unused they become liable to disease, defective in growth and age quickly.
Hippokrates of Kos (‘The Father of Western Medicine’)

The reason I use a quote from Hippocrates is that he lived from c460 to c370 BC, many, many years before ‘at least five times a week’ was produced. Hippocrates knew then that being active was beneficial. ‘At least five times a week’ did its best to provide the clinical evidence to back up why we should invest more resource in intervention-based physical activity. It also added to the existing movement of clinicalising exercise. In 2001 the National Quality Assurance Framework for Exercise Referral Systems (NQAF) was produced by the NHS. Based on the principles of the American College of Sports Medicine (ACSM) exercise referral model, it developed a pathway that enabled clinicians to refer patients for exercise. Prior to the NQAF, there was a steady organic growth in exercise referral and, without a framework on which to hang this process, it was deemed important to have some kind of formal pathway agreed with clear competencies identified to assure the systematic referral process.

I can’t help thinking that exercise referral is so yesterday. It now appears that we have developed a sector that is reliant upon receiving inactive clients via clinical pathways. And if new clients don’t come via a clinical route, we have introduced clinical screening that makes sure they end up on a pathway that considers their clinical risk.
If you are looking for an example of how ‘clinicalisation’ has crept into everyday customer relations, may I introduce, as Petrocelli would say, Exhibit A.

An inactive person (potential new customer) appears at the door of your facility wanting to access your superfabulous gym. They have not been active for some time. They are introduced to Luke, an instructor who has a Level 3 qualification in exercise instruction. Luke knows more about exercise than any general practitioner. The visitor is asked to complete a number of forms and one of the questionnaires is a variant of the internationally recognised Physical Activity Readiness Questionnaire (PAR-Q). The client ticks a ‘yes’ box and this simple tick triggers a process the value of which I cannot begin to fathom. It’s a process that adds an immeasurable amount of bureaucracy to what is supposed to be a simple process. It triggers a medical approach that might actually prevent this potential customer from ever becoming a customer. In fact, it might even put them off becoming active. 

Hands up all those who use a P-ARQ to assess a customer’s state of readiness to become active. Now, hand up all those who use the PAR-Q only for those who access the gym? Why not swimming? Why not squash? Why not football? I would be prepared to take a guess that more people have cardiac arrests – and possibly have serious injury or even die – from activities other than gym use.

It is worth considering the rationale for the use of PAR-Q from a practical perspective for a few minutes. If we insist on using a PAR-Q-type assessment of client suitability to become more active and a customer has a reason to tick ‘yes’ they are automatically advised to seek medical advice before progressing their personal choice to become more active. In fact, many Instructors insist that a letter is supplied from the customer’s doctor before being allowed to progress their activity intentions. This, in my opinion, is a clear waste of resource, effort and motivation.

Let me ask another question. When was the last time you made an appointment with the doctor for a non-medical reason? When did you last make an appointment to ask for a letter so that you can go to the gym? Do you even know how much it costs for a doctor’s letter these days? £15? £30?

Let’s just remind ourselves that a GP is simply that: a general practitioner. They are not exercise specialists. They are not even taught about the benefits of exercise in any great depth during their five-year training. So this letter you have asked for: is it really worth the paper it’s written on?

I’m not sure why exercise became so clinically orientated. If it continues in the vein that is currently being promoted I can see many people having a reason not to exercise (be active) and all we will do is build a stiff rod for the sector to be beaten with.

The thing for me is this: everyone has a right to be active. It’s a fundamental human right, one that has been built on evolutionary need. It seems to me that the sector is currently becoming more selective regarding who we want to help. Natural selection is also an evolution-based theory. Who said you have the right to select who is or is not allowed to be active?

The Commissioner is a senior health improvement specialist with extensive experience of the sport, leisure and culture environment.

The Leisure Review, February 2014

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“Let’s just remind ourselves that a GP is simply that: a general practitioner. They are not exercise specialists.”
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