The process employed to establish and regulate clinical exercise physiologists
Establish an appropriate regulator for healthcare professionals
In the UK, the PSA is an independent organisation, accountable to UK Parliament, tasked with reviewing the work of the regulators of health and care professionals, governed by legislation. The PSA also accredits organisations that register health and care practitioners not regulated by legislation, establishing accredited registers. PSA-accredited registers demonstrate that a registered health professional who is not regulated by law has achieved the highest standards in governance, education and training and professional standards required within their scope of practice, while also demonstrating competency in the management of the register, complaints handling and information including fitness to practice monitoring. The focus of regulation in this manner is ultimately to ensure patient safety.
The Registration Council for Clinical Physiologists (RCCP*) held a PSA-accredited register for clinical physiologists (specialisms include cardiac, gastrointestinal, respiratory, sleep and neurophysiologists, audiologists, educational audiologists and hearing therapists) until the transfer to the AHCS. Clinical exercise physiologists were identified as having similarities to clinical physiologists in terms of knowledge, skills and training, and the RCCP had the ability and processes in place to accredit university-level degree courses. In June 2020, CEP-UK approached and subsequently agreed to work with the RCCP to establish clinical exercise physiologists on their PSA-accredited register.
Scope of practice and standards of proficiency
A scope of practice was developed by CEP-UK and benchmarked against international standards (scope of practice v2[2].pdf (clinicalexercisephysiology.org.uk). A scope of practice describes the procedures, actions and processes that a healthcare practitioner is permitted to undertake, in keeping with the terms of their regulator.18 It is required for all regulated healthcare professionals in the UK.19 A unique aspect of the clinical exercise physiologist scope of practice was that it contained a list of long-term health conditions (cancer, cardiovascular, frailty, renal, mental health, metabolic, musculoskeletal, neurological/neuromuscular and respiratory/pulmonary) for which there is an evidence base supporting the efficacy of clinical exercise services.3
Similarly to the scope of practice, all regulated healthcare professionals in the UK work towards a specific standards of proficiency (SoP) document which covers professional autonomy and accountability, and the skills required for practice. In addition, the AHCS requires all registrants to comply with the AHCS Good Scientific Practice (GSP) standards. After consideration by CEP-UK, this was also deemed applicable for clinical exercise physiologists.
Curriculum standards
While regulation was being pursued, it was recognised that curriculum standards were required to provide guidance for new university programmes on what would be required to meet accreditation standards. The curriculum standards were developed for creating new clinical exercise physiology master’s degrees (MSc). Curriculum standards ensure consistency in knowledge, skills and experience of the workforce, and help university programme teams to interpret definitions in the scope of practice.
The curriculum framework developed by CEP-UK underwent several iterations (members listed on the published document), was benchmarked against international standards for clinical exercise physiologists (or equivalent) and was comparable with UK standards for other healthcare professionals.20 The published curriculum framework consists of six broad headings, including (1) pathophysiology and clinical management, (2) screening and risk stratification, (3) assessment of health status and functional capacity, (4) design of exercise interventions, (5) exercise implementation and delivery, and (6) behaviour change and communication. Each broad standard outlines the specific knowledge and skills required in more detail. The curriculum framework also outlines the compulsory practice-based learning requirements and practical competency assessments.
CEP-UK sought consultation and feedback with academics and practitioners in the field via an online survey before publishing the curriculum framework. Respondents (n=31) consisted of academics (65%), clinical exercise practitioners (19%), clinical exercise service leads (7%) and other professional organisations (9%). Around 90% of respondents acknowledged that the curriculum framework content devised by CEP-UK met the standards required of an MSc-level degree, with 94% identifying sufficient detail within the document to allow universities to design and implement content within their postgraduate programmes. After acting on relevant feedback, the final iteration of the curriculum framework was presented at a curriculum sharing event to disseminate this document to stakeholders with 80 attendees representing >20 institutions from the UK. The curriculum framework document was published on the CEP-UK website in May 2022 (figure 1). This document will be reviewed and updated after 3 years (May 2025).
Figure 1CEP-UK milestone timeline. AHCS, Academy for Healthcare Science; BASES, British Association of Sport and Exercise Sciences; CEP-UK, Clinical Exercise Physiology UK; MSc, master’s degree; RCCP, Registration Council for Clinical Physiologists.
Registration
Equivalence pathway to registration
Prior to registration, unregulated clinical exercise physiologists have been working across public and private sectors within clinical exercise services (~890) in the UK for over 25 years.8 21 These individuals identified themselves by various titles (eg, exercise physiologists, exercise scientists, sport and exercise scientists, exercise specialists and advanced exercise instructors) and held a variety of qualifications.8 21 It was apparent from the previous audit of clinical exercise services8 that many of these individuals possessed associated undergraduate degrees (eg, sport and exercise sciences) and postgraduate degrees (eg, exercise science) and/or vocational qualifications (eg, advanced exercise instructor in cardiac rehabilitation), together with years of hands-on practical experience that would likely meet the required standards to become a registered clinical exercise physiologist (figure 2). It was therefore necessary to develop a pathway for these individuals to become registered.
Figure 2Equivalence pathway for individual registration. AHCS, Academy for Healthcare Science.
CEP-UK used the content within the curriculum framework and scope of practice to create a template application form to allow these professionals to display their knowledge, skills, behaviours and experience. The regulator (at that time the RCCP) submitted a change notification form to the PSA requesting the addition of clinical exercise physiology to their PSA-accredited register. In August 2021, the PSA accepted the addition of clinical exercise physiologists and the clinical exercise physiology equivalence pathway was opened in December 2021. This was effectively the time point at which clinical exercise physiologists became recognised and regulated health professionals in the UK. For an applicant to be successfully registered via the equivalence pathway, they need to have completed 6 years of training/work experience across education or clinical exercise settings. One option to fulfil this criterion is an undergraduate degree in a sport and exercise science-related subject, plus 3 years of experience and training in the delivery of clinical exercise covering all the pathologies outlined in the CEP-UK scope of practice. A second option is an undergraduate degree, supplemented by a postgraduate degree in clinical exercise physiology or equivalent, and then 2 years of experience and training in the delivery of clinical exercise. In both options, applicants must display knowledge and experience in all pathologies within the CEP-UK scope of practice. Qualifications are required to support applications, alongside current employer references, work history and an overview of an applicant’s knowledge, skills and work experience across each of the CEP-UK curriculum standards. For each pathology/long-term condition, applicants need to demonstrate their competency in: pathophysiology, screening and risk assessment, designing an exercise intervention, exercise delivery and behaviour change and communication. Additionally, an applicant is required to provide evidence of professional indemnity insurance and public liability insurance to access the register (either via employer or personal indemnity insurance).
Scrutineer training and application assessment
A requirement for the accredited register was to appoint application scrutineers for the assessment of equivalence applications. Scrutineers were selected from the CEP-UK steering group based on their ability to become registered clinical exercise physiologists themselves through the equivalence pathway process and satisfactory compliance to the scrutineer role description. Scrutineers undertook an onboarding process whereby they underwent training in application assessment, including group workshops, consensus agreement regarding application merit and quality assurance checks through the process of auditing all assessments during the initial phase of equivalence. In-depth training was given concerning the criteria for acceptance for applicants, including qualifications, experience and coverage of core competencies, alongside application/document completion and potential outcomes of any application (accept, request further information, reject or assessor review for additional assessment). The target for assessment completion is 28 days from receipt of any application.
Graduate route to registration through AHCS (as part of the transfer of the RCCP to the AHCS) accreditation from January 2023
The CEP-UK curriculum framework and scope of practice alongside the AHCS Practitioner SoP and AHCS GSP standards are collectively used by the AHCS to assess MSc courses for accreditation. CEP-UK held a curriculum sharing event in September 2022 to help university programme teams understand the requirements for accreditation, share ideas on how to deliver a clinical exercise physiology MSc programme as well as meeting clinical and practical requirements. The AHCS opened the graduate route in January 2023 for MSc programmes to apply to be assessed for accreditation by the AHCS (figure 3). The accreditation involves a desktop review of submitted paperwork by the AHCS head of accreditation and a registered clinical exercise physiologist with expertise and experience of higher education processes. If the desktop review is deemed satisfactory, then a site visit is arranged with the university programme team, local management as well as placement providers. Feedback is provided at all stages of the process. Recommendations to the Education, Training and Standards Committee (ETSC) following the site visit include accreditation, accreditation secondary to satisfactorily addressing conditions or accreditation refused. Once the university MSc course has final notification of accreditation in writing, their students graduating from the MSc course are automatically eligible for registration as a clinical exercise physiologist on the AHCS-accredited register.
Figure 3AHCS accreditation process flow chart. AHCS, Academy for Healthcare Science.
The graduate route for registration involves the completion of an accredited postgraduate MSc in clinical exercise physiology after an undergraduate degree involving the cognate discipline knowledge. Graduates are required to pass each module within the MSc course, including the fulfilment of a minimum 250 hours of practice-based learning, a minimum 140 hours of which is required within clinical placement and successful completion of the Clinical Assessment of Competencies (CAP) examinations for each set of curriculum standards. Completion and passing of an AHCS-accredited MSc, alongside the CEP-CAP assessment, will ensure that graduates have met the CEP-UK scope of practice and AHCS Practitioner SoP and GSP, and will therefore be eligible for registration. The first MSc Clinical Exercise Physiology Programme was accredited in August 2023.
Maintenance of registration as a clinical exercise physiologist
A clinical exercise physiologist is registered (via the equivalence pathway or graduate route) for a period of 1 year. Following this time period, individuals are required to reconfirm registration on an annual basis and pay the required fees.
A requirement for ongoing registration is Continuing Professional Development (CPD). To minimise the risk of harm to patients, AHCS registrants are required to demonstrate that they are fit to practise through CPD, both in terms of their competency and conduct. This is important in supporting a culture of continuous learning and improvement, as well as ensuring the professionalism of registrants through shared experience and community development. CPD helps registrants maintain or develop competence and fitness to practise and is an essential requirement for registration. CPD can take many forms, such as professional activities, formal education, work-based learning or independent learning. At present, individuals are required to complete sufficient self-managed CPD per annum that demonstrates currency of learning within their specialism, while keeping a log of all activities ready for AHCS audit requirements. If audited, registrants submit a personal statement summarising practice history for the previous 2 years and any CPD activities undertaken. If they do not maintain CPD, individuals are removed from the AHCS register.