Integrating sport and exercise medicine clinics into the National Health Service: a qualitative study

Decline of SEM in the NHS?

There are now over 147 SEM doctors on the General Medical Council Specialist Register, and every year approximately nine new specialist trainees begin training in the UK.^{5 6} In recent years, there has been a decline in growth of the speciality, highlighted by a loss of SEM training posts in Scotland and Wales.^{7 8} This drop can be attributed to several factors such as the loss of momentum following the London 2012 Olympic games (a similar loss of momentum has been observed after previous olympic events).⁹ Perhaps due to the low number of National Health Service (NHS) SEM posts, the majority of SEM trainees work in the private sector once they become consultants, and, anecdotally, some no longer work within NHS settings at all despite the fact that many view it as a desirable work setting.¹⁰

Current relationship between SEM and the NHS

The Faculty of Sport and Exercise Medicine (FSEM) promotes SEM as a cost-effective approach to the prevention and management of illness and injury and is calling for an increase in SEM consultants in the NHS.¹¹ In support of this, one study found that 93% of the clinicians surveyed felt that there was a role for SEM in the NHS.¹² Given the training and expertise of SEM consultants, they may be considered well placed to aid the NHS in dealing with high levels of physical inactivity, and the burden placed on the system by musculoskeletal (MSK) issues.¹¹ Current NHS SEM services have been shown to reduce surgical interventions, reduce the number of scans requested and improve patient satisfaction, and can therefore be beneficial to the NHS.¹³

To establish a mutually beneficial relationship, more clarity is needed over the role of SEM in the NHS. The need to better define how SEM fits into the NHS has been raised for many years.^{3 7 14} Though several case studies highlight examples of integration across the UK, more research is needed to explore how SEM can be better integrated into the NHS.¹³ As such, this study aims to explore what individuals working in SEM think about what services an NHS-based SEM clinic could provide that would be of most value, and the barriers to creating and integrating such a service within the NHS.

Participants and recruitment

Stakeholder groups were defined based on identifying individuals with experience and knowledge of the speciality of SEM, and of working in the NHS. Participants were recruited (February–April 2018) from these stakeholder groups subject to the inclusion criteria (table 1) using purposive sampling by email.¹⁵

Data collection

The interview schedule is provided in figure 2. Each participant was given a unique anonymised code. These data were recorded in a key file with the participant speciality (ie, the stakeholder group interviewees’ belong to). No other personal data were recorded. All interviews were conducted by the lead author and digitally audio recorded. All recordings were transcribed verbatim. Any identifiable information discussed during the interviews were redacted from the transcripts. Interviews continued until data saturation was reached.^{16 17}

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Data analysis

An inductive thematic analysis approach was taken to analyse the interview transcripts.¹⁸ In terms of epistemology, a realist approach was adopted as the research team believed there was likely to be a single truth in answer of the objectives, in keeping with the realist paradigm.¹⁹ Braun and Clarke’s six-step process was followed and used to extract meaning and concepts from the data in order to identify patterns, and ultimately generate themes, which were managed using Trello software (version 3.40).^{20 21} To ensure reliability, two members of the research team started the coding process by reading, five (33%) randomly selected interview transcripts separately and discussed their coding decisions together, working through differences of opinion until a consensus was made. A reflective journal was kept to determine the extent to which thoughts and observations were data-driven and without researcher influence, in order to manage unconscious bias. Once all interviews had been coded and themes had been finalised, five randomly selected transcripts were given to the same reviewers to code to check whether extracts represented the themes appropriately. There was a 79% similarity. A result of over 70% has previously been deemed acceptable.²²

Demographic information

Seven stakeholder groups were identified (table 2). Sixteen individuals were invited to participate in the study, and 15 participated (93%) covering all stakeholder groups. The interviews lasted 23 min 10 s on average, ranging from 14 min 38 s to 31 min 03 s. The stakeholders included 4 female and 11 males with an average age of 41 (range 34–47) years. They were all working in the UK.

Interview results from consultants and teaching staff

Five themes and 15 subthemes were identified from the transcripts (table 3).

1. Roles believed to be key to being an SEM clinician

2. Services SEM clinics can offer that would provide the most value to the NHS

The management of non-surgical MSK injuries (both acute and chronic) and concussion were highlighted as the two key areas in which SEM could add the most value to the NHS.

4. Clinicians’ recognise there are common barriers to setting up an SEM clinic

5. Leaning points for setting up SEM clinics

Defining a place for SEM in the NHS

The management of MSK injuries and concussion were highlighted as the two key areas in which SEM services can provide useful services to the NHS. Regarding MSK injuries, this includes both acute injuries usually presenting via A&E, and chronic injuries usually presenting via general practice. The benefit of utilising MSK ultrasound and injection therapies in the management of MSK injuries was also identified by several stakeholders as a key service that SEM clinics can provide. MSK consultations are thought to account for nearly 30% of all general practice consultations with nearly 82% not requiring surgery.^{23 24} These patients will therefore typically re-present in general practice recurrently which is an inefficient use of NHS resources.¹⁴ SEM consultants play a key role here in non-surgical management, enabling cost-saving and improved pathways for patients.¹³ Regarding the presentation of acute injuries, A&E departments are notoriously time pressured and overworked.^{25 26} Fundamentally, A&E does not have enough time to assess acute injuries thoroughly, and the acute swelling post injury means A&E potentially is not the ideal setting to assess certain injuries. Given that 7.7% of A&E attendances are directly related to playing sport, SEM clinics may result in reduced workload for overstretched A&E services without the need to outsource to private care.²⁷

Concussion is well covered on a SEM syllabus and the management of concussion was also highlighted as a key service that SEM clinics could provide.⁴ Concussion is also a common presentation, and given the majority of GPs and A&E doctors do not feel confident in how to manage it, this is an area that SEM clinics could help relieve pressure from overloaded departments.^28–31

SEM, exercise medicine and the NHS

Physical inactivity costs the UK economy over £7.4 billion a year.³² To begin to address this, FSEM recently launched ‘Moving Medicine’, a website designed to support healthcare professionals integrate PA advice into clinical practice.³³ For the day-to-day clinical work of a SEM doctor, it is unclear exactly what an exercise medicine service within the NHS could, or should, look like, and whether SEM clinics should facilitate exercise medicine. The value of exercise medicine is not being debated, rather the question is regarding the most effective method and setting for delivering it.³⁴ While it is always essential to provide brief PA advice where appropriate as per NICE guidance, the findings of this study suggest SEM clinics may not be the most effective setting for having a heavy exercise medicine focus.³⁵ SEM clinicians of course have a responsibility to promote, integrate and facilitate exercise as medicine within society and the healthcare system. However, exercise medicine may be best dealt with through public health initiatives to promote both individual and population-level change rather than through individual-level behaviour change promoted through SEM clinics, an idea that has been highlighted previously.³⁶

Key barriers to integrating SEM into the NHS

The need for SEM to build collaborative relationships with other specialities was highlighted in this study and has been emphasised previously.^{24 37} Caution should be applied to not cross the boundaries of other specialities, but instead take a cooperative approach and explain how SEM can add value. Another major barrier appeared to be awareness of the speciality among other medical professionals. If the knowledge of the speciality is poor, it is hard to cultivate a reputation, resulting in SEM clinics not receiving referrals that should have been sent to the service.

What are the next steps?

The findings of this study have highlighted a key solution to better incorporating SEM into the NHS is to improve education about SEM among the medical profession, a finding supported by previous studies.^{12 38} It is unsurprising that other professions have a lack of knowledge about the SEM speciality, particularly in relation to how it works as a speciality within the NHS, when the speciality itself appears to not have clear definitions over its place in healthcare. SEM urgently needs to confirm its identity within the NHS.

Despite the barriers mentioned in this study, several SEM services are already in place.¹³ It is important to ensure that the value of SEM clinics is observed and documented to ensure they continue to be funded by the NHS. Otherwise, we risk the NHS not benefitting from the services that SEM clinics can offer.

Strengths and limitations

This study had several strengths including a high inter-rater reliability to ensure trustworthiness of coding, achieving data saturation (despite a limited number of interviews conducted) and utilising a qualitative design to uncover insightful data. As ever, there were limitations such as the potential influence of the interviewer on data collection and analysis. A reflective journal was kept to minimise this. Interview participants were selected depending on them being viewed as a stakeholder by the research team and was therefore open to selection bias. It may have been beneficial to get the views of other SEM-related specialities such as podiatrist, chiropractors and osteopaths. In addition, opinions could be explored from individuals that work outside of the NHS, policymakers or government figures. It would have also been of benefit to interview patients that had attended SEM clinics to explore what they thought of the services they had received. Future studies could consider seeking opinions from a broader range of stakeholders.