Moving healthcare professionals – a whole system approach to embed physical activity in clinical practice

There is substantial evidence supporting the positive impact of behavioural interventions to promote physical activity and healthy lifestyle [1]; however, there is also a need for more effective programmes and collaborations [2]. At present, healthcare professionals appear to be struggling to deliver these messages, and response from patients has been mixed [3]. In fact, both adult and older patients often feel they are not receiving physical activity interventions or guidance from their general practitioners (GPs) [4, 5].

Research has shown that primary healthcare professionals such as GPs already frequently discuss physical activity with their patients, although this advice is typically brief, non-specific and therefore fails to capitalise on the opportunity to change patients’ behaviour and engagement with a more active lifestyle [6]. However, even within medical specialities there is a significant individual inter-clinician variability on how exercise and physical activity is prescribed to specific patient groups, for instance with cardiovascular comorbidities, which highlights the lack of standardisation and recognised guidance [7]. Furthermore, interventions are generally on a single encounter basis and are often inadequate in driving change in physical activity engagement and function [8]. There is therefore a great need for both GPs and physicians to be effectively trained to promote physical activity and prescribe exercise [9, 10]. Recent surveys found that many physicians, including newly qualified doctors, lack the confidence to deliver physical activity counselling; and despite changes in national guidelines in the United States (US), counselling behaviour has not increased [11]. At undergraduate level, in English medical schools there is widespread lack of training on physical activity promotion [12]. Among other healthcare professionals such as physiotherapists, research has shown some improvement in their understanding of physical activity counselling [13], but there is still generalised poor understanding [14] and wide-spread unawareness about the current physical activity recommendations [15].

On the other hand, patients may have unrealistic expectations about what healthcare professionals can deliver in terms of physical activity counselling, which in itself is a significant barrier to successful intervention [16]. In primary care this barrier to integrate physical activity promotion is compounded by reported lack of time, skills, cost reimbursement, as well as adequate screening [17]. In addition, the lack of co-ordinated large scale initiatives reduces the impact of any intervention. There is a need not just for better community-based collaborations with sport, leisure and fitness providers [18], but also the improved infrastructure, such as access to walking or biking, that was shown to define effective population-level interventions [19].

Despite the challenges physical activity promotion remains a cost effective and viable option of health promotion and prevention [20], and in fact, primary care work force and GPs are probably the most cost-effective healthcare professionals to deliver physical activity counselling [21]. However, attitudes and behaviours among healthcare professionals are influenced from the early career stages, as the confidence in delivering physical activity interventions among medical students and doctor is associated with their own personal exposure and engagement with physical activity [22]. In order to address the specific needs of different healthcare professionals, the Moving Healthcare Professional Project (MHPP) was developed as an overarching model capturing all stages of medical education, from undergraduate and postgraduate to continuing medical education. It has been shown to have the potential to drive and embed cultural changes within the health professions that could significantly improve the quality of physical activity counselling and promotion [23, 24]. This study looks at the early implementation of the MHPP in the England and its ongoing development.

Considering the World Health Organisation (WHO) predicts that by 2020 two thirds of disease burden worldwide will be due to poor lifestyle choices [26], interventions to introduce lifestyle medicine teaching into undergraduate and postgraduate health education are expected to have a significant public health impact [27] and are in line with the WHO global action plan on physical activity (GAPPA) to reduce the prevalence of sedentary lifestyles [28]. In this context, the MHPP model is a coherent, co-produced whole system educational approach to embed effective physical activity counselling into routine clinical training and ultimately everyday clinical practice. It presents a viable and transferrable model for change that can be replicated for different topics and challenges, and its use of different learning styles and preferences across the professional “lifespan” ensures comprehensive coverage. Ultimately, the MHPP provides a framework for change that we hope will underpin a step change in the approach to physical activity in clinical practice in England for today and tomorrow’s healthcare professionals.

MHPP was designed to take a whole educational system approach to embed physical activity into clinical practice, including the upstream integration in undergraduate education as well as the downstream capability development with qualified healthcare practitioners. The core interventions focused on undergraduate, postgraduate and peer-to-peer education as well as eLearning, which were chosen as no single educational approach used in isolation has been shown to provide effective and enduring changes among healthcare professionals [7, 8, 11]. These core elements were supported by a consistent public health awareness campaign reiterating the importance of physical activity advice from clinicians. By taking this “whole educational life” approach, the model is designed to eventually become redundant as the clinical social norm shifts toward the routine integration of brief advice on physical activity into daily clinical practice for all clinicians in England.

The MHPP’s implementation of spiral education into undergraduate curricula addresses the inconsistent education on physical activity counselling and exercise prescription that healthcare students receive [12, 22]. In addition, the postgraduate curricula changes driven by FSEM also address the perceived lack of adequate training among trainee doctors, who report poor knowledge, skills and competence to provide patient-centred exercise counselling and exercise prescription [29]. Spiral integration was chosen as an established approach used successfully to embed a common message across multiple different topics and learning experiences [30], reducing the risk that the message only reaches those who are already motivated, thus continually reinforcing the benefits of physical activity across multiple disease conditions and in the context of both prevention and treatment of disease.

The inclusion of a large eLearning component is in line with previous research supporting the use of this modality among medical students, where a large meta-analysis of 59 studies showed equivalent satisfaction and effectiveness when compared with traditional teaching methods [31], and also reflects the growing trend to deliver postgraduate medical education for busy healthcare professionals through e-learning. The MHPP builds on this with a multi-faceted model that implements eLearning alongside face-to-face training, which has been shown in different studies to be both practical and cost-effective in helping healthcare professionals deliver a self-management support programme and physical activity counselling to chronically ill patients [32–34]. The peer education ‘champions’ focused on delivering training through existing programmed teaching time which was especially effective in reaching GPs but also provided a recognisable context for CPD training. This approach was further strengthened by having ‘peer educators’ who could relate the theory to practical case studies and share tips and hints for the practical application of the evidence. The use of trained healthcare professionals (“Clinical Champions”) to deliver capillary training on physical activity counselling and prescription is not only a novel approach built on the best evidence available, but also a strategy that addresses the limitations of models based solely on eLearning [35].

Taking a whole educational system approach to embed cultural change in medical education is complicated and requires strategic horizon scanning as well as well-resourced implementation and delivery. In addition, like all novel interventions, it comes with challenges as well as limitations. The MHPP has benefited from having PHE, the national public health agency responsible for England, to act as pivot between all key national partners involved in developing a whole new educational system. Nonetheless, a public health body in isolation is not sufficient in itself to deliver these wide-ranging changes, and the MHPP represents a feasible and synergistic co-production model where other healthcare professional organisations, trade unions and education bodies collaborate toward a shared goal maintaining high and consistent standards across the board. The use of established stakeholders such as the BMJ Group provided resources and platforms with high penetration and across all medical specialisms in England. The wide reach of BMJ publications, as well as recognised CPD accreditation, explains some of the high uptake and completion of eLearning modules, and we understand that using such platforms may not be feasible in every location, although it emphasises the advantage of using established media rather than radically new dissemination platforms.

In terms of evaluating the effectiveness of the programme, the focus is on its impact on confidence and capability to provide brief advice, as there is already a clear and consistent evidence base supporting brief advice from healthcare professionals on physical activity leading to improved rates of physical activity uptake in patients [36]. However, issues of objectivity and impartiality in the evaluation could arise when a single agency oversees the process. To minimise this bias, the evaluation of the MHPP has been delegated to independent academics at the University of Loughborough and Sheffield Hallam University, so we are therefore unable to conclude on the effectiveness of the MHPP. The challenge of evaluating multiple interventions across different stakeholders remains, and this complexity may yet affect the validity of the evaluation. Yet the evaluation will add to our understanding of the optimal educational model, shed light on the interconnectivity between components of the programme, the differential impact with different groups of clinicians and specific barriers emerging.

This technical paper sets out a novel whole system educational approach to embed routine brief advice on physical activity into every day clinical practice. The approach used could provide a model for future public health actions aiming to promote cultural changes and shift educational paradigms. However, future success will depend on objectively recognising, evaluating and addressing the barriers and facilitators to the implementation process. The initial engagement with the programme has been significant but time and further analysis will tell if the upstream implementation of the programme is achieving its goal of major cultural change among practitioners and the ultimate outcome of supporting more people to get active every day in England.