DISCUSSION
This research has provided three key findings. First, the key services that SEM clinics can offer the NHS are in the management of MSK injuries and concussion. Second, the main barriers to setting up a SEM clinic are getting managerial agreement, conflict with other specialities and a lack of awareness of the speciality. Third, the main perceived solution to reducing the impact of the identified barriers is to improve education among the medical profession about the speciality of SEM.
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.