A conversation with Natasha Jones, President of the Faculty of Sports and Exercise Medicine, William Bird GP, Intelligent Health and Dan Fitzpatrick, Sport and Exercise Medicine Registrar (ST5), University College London Hospitals .  

Podcast transcript

General Introduction: 

You are listening to the Four Ways Forward podcast. A podcast exploring how physical activity can help people live healthier, longer and more independent lives. “You may be using physical activity to improve your mental health, improving your joint health, skin health. It just seeps into so many areas.” This is a podcast where we hear from health experts on the importance of movement for our health and the health of the NHS. 

“I too want to feel the benefits of that. I would like my mental wellbeing to be better and be part of a community and do something with people that are like minded.” A podcast on how we can empower health and care professionals. “Just taking a physical activity history can be a game changing moment in a consultation.” A podcast discussing exercise in all its forms.  

William Bird GP, Intelligent Health: 

So welcome. This is one of the series of podcasts for the Four Ways Forward, which is a combination of work from NHS England and Sport England and real pleasure to be here. My name is Doctor William Bird. I am a GP and I’ve had a real interest in physical activity, promoting it to both GPs and patients for many years. 

Back in the 90s I helped set up green gyms and health walks, and I’ve been working all the way through in training up GPs and getting people more active. So, it’s part of my DNA because I think it’s so important in clinical work to get that physical activity somehow embedded in all our conversations. I’m delighted to be joined by Natasha Jones. Natasha, if you could just introduce yourself.  

Natasha Jones, President of the Faculty of Sports and Exercise Medicine:  

Yeah. Thank you, William. So, I’m consultant to sport and exercise medicine. I work in Oxford, and I’m also president of the faculty as both an exercise medicine and have been director of Moving Medicine, which is a health care facing initiative for the last eight years. 

I’ve had I also had a lifelong interest in physical activity as a sort of key determinant of health. And I have had a career long experience in trying to influence that at multiple levels. 

William: 

Thanks very much. And, Dan, you’re at the kind of other end of the career, so to speak, as a sport and exercise medicine Registrar. So, can you just tell us how you got into that? 

Dan Fitzpatrick, Sport and Exercise Medicine Registrar (ST5), University College London Hospitals:   

Yeah, absolutely. Thanks for doing so. I am sports next sports medicine registrar based in London, and I’m also a physical activity, clinical champion. I actually trained as a GP before going into sports medicine. And I think one of the things that, really drew me into  it was work in sport, is MSK medicine; actually the exercise medicine and physical activity medicine aspect of our specialty which allows us to really influence the health, and such a wide range of patients and people who maybe don’t think they are patients across the whole life span.  

William: 

So, I’m going to go back to Natasha – why is it so important that we get healthcare professionals understanding about physical activity?  Surely, it’s an obvious thing for patients to know. And, I think that’s what people say. And are we medicalising it by kind of trying to always talk about physical activity, you know, why is it important and why should we be doing it? 

Natasha: 

Since I became a doctor, in 1992, the evidence regarding physical activity in terms of it’s a tremendous preventative and, management qualities, it has exploded. When I trained as a medical student back in 1987, we weren’t taught to take history of physical activity. We weren’t taught to, in any way regard physical activity as a key determinate of health. 

But the evidence subsequently has shown us that we absolutely must in order to expand a patient’s lifespan, but also, ensure that they live in good health, towards the end of their lives. Part of the problem over the last 30 years is that they, practice, hasn’t kept up with the evidence base, and we’re still not taught to take histories regarding physical activity. We’re still not taught to bring that into our patient’s management plans, even though, NICE guidance tells us that we must.  

William: 

Thanks. And I think, then I think a lot of colleagues still say, oh, it doesn’t make any difference. You know, it’s like talking about weight loss. You know, they just won’t listen. But actually, I think the facts don’t agree with that. I think there’s some evidence to show that actually, if we all did it, it would make a big difference. 

Dan: 

Yeah. I think, you’re absolutely right. And I think there’s some evidence that has shown that 1 in 4 people would become more active if their health care professional advised it. And I think we see in lots of different areas of people’s lifestyles that the opinion of a health care professional can be really powerful for people. 

So we consider that one in four people who maybe aren’t as active as they could be, actually, that’s nearly 3 million people who would be less inactive in their day to day lives. And what the rest of the evidence shows us is actually just those people who become a bit less inactive can have such huge changes in their risk of all sorts of non-communicable diseases. 

William: 

That’s kind of reassuring, because people often feel that this is a conversation that’s going to go nowhere. But, you know, if it means a small number of that 3 million people being less active, that that’s really extraordinary. People do trust their doctors. Still, I know it’s changed a little bit, but there’s still that. 

But also, the sheer number of consultations that we have, you know, almost a million a day. Natasha, I think you’re going to talk about some of the challenges. 

Natasha 

Yeah. So, I think we’ve already talked a little bit about the sort of underlying cultural challenge, in medical education and, and beyond medical education as well, regarding the importance of physical activity. 

But I think, the challenges go well beyond that because advising somebody about physical activity, takes skills. It’s often a confrontation or feels a confrontational, intervention. And if you’re not very careful, you can leave your patient feeling judged or feeling like you think that they’re not doing enough to help themselves. And you can end up leaving the consultation with some sort of negativity, which isn’t necessary. 

So, teaching the skills to enable patients to understand their own reasons for change, in their own reasons to become more active. And the positives for them is really important. And that is essentially the behavioral change science, which stems, of course, well beyond physical activity to pretty much all lifestyle and many other health care interventions. 

But we’re not routinely taught about behavioural change science and about behavioural change conversations at an undergraduate level. And many professions aren’t taught that at a postgraduate level either. So really, important to understand that it’s not as simple as telling somebody to move more. It requires more skills than that. And we’ve heard from our colleagues across health that many people don’t feel they have those skills so avoid those conversations.  

I think the other reason that people avoid those conversations is because they don’t feel supported to have those conversations within the environments that they work. So, for example, in secondary care, on acute medical wards where we know that hospital associated deconditioning is hugely important in terms of quality of life, and readmission rate and length of stay and, and, and the culture within wards isn’t often isn’t permissive enough to help staff understand their role and their responsibility to keep people as active as possible during their stay.  

William 

Yes. And I think when I first started all of this, those mean I remember you probably remember the ACSM (American College of Sports medicine guidelines for Exercise testing and prescription) book about every condition under the sun and then what exactly the prescription was for that person. And people were terrified because they thought, well, if someone’s got rheumatoid arthritis or someone’s got osteoarthritis, what does that mean? How can I recommend? So, there was all this. It was so kind of medicalised that people just felt they were inadequate, didn’t have the confidence to do it. And the other thing, of course, is that, you know, at the time when we had cardiac rehab and pulmonary rehab, you had trained people giving us advice to certain conditions. 

And I think a lot of GPs said, I just don’t have that training. But I also am worried that I’m going to do more harm than good. And I think that has prevailed all the way through. It’s getting better. And I think that kind of feeling about, you’re going to do some damage to someone has kind of slightly retreated in the fact that we just want someone to move as opposed to a prescription. 

So, I think if we can get that much more of it as a GP’s, that you really should be just saying to patient to just that there’s a bit of walking, a bit of movement. We don’t want them waiting for a pulmonary rehab nurse for six months for them to come along, and they’re sitting there doing nothing when that time, because they’ll just decondition so quickly. 

So, I think it’s that permission that we’re giving GPS to be able to have that confidence, to be able to say, just move, do something very gentle, get going. And yes, there may be some specialist skills that need to be for very small groups of people or if they want to really increase their physical activity to a more vigorous level. 

That is a specialist. But getting people to move is the basic thing that really should be embedded into every GPs kind of mind. 

Natasha: 

And of course, it’s not just GPs within primary care. And in fact, increasingly it’s the wider multidisciplinary team within primary care who have the opportunity and perhaps the time to have these conversations with patients; and perhaps driving this through along with the protocols and guidelines that they follow for chronic disease management alongside NICE guidelines, would also help. 

So, I think there is a cultural thing, but I think there’s also a contractual element that could be strengthened. I think the more we can drive this through contracts, the easier it will be for people to realise that this isn’t a dangerous thing to do in fact, the dangerous thing to do is to not discuss physical activity with your patients. 

Dan, do you have any thoughts about that? 

Dan: 

I agree with a lot of what you’ve both said, and I think, William, you know, I work as a GP, when you speak to people, I think in general GPs want to try and help their patients to do it. And with lots of things, there is often that bit of fear of what if something goes wrong or what if I’ve done something that that causes some harm. But I think that because people want to do the best thing by the patient, if we can provide that education about what we’re actually talking about, which is starting off with getting people to just move a little bit more, and that actually the risks for most people aren’t very big at all.  

Then, actually, I think that really takes away a barrier that I’ve often seen, and that comes out a lot when you do go and do these education sessions to, all sorts of health care professionals so that we can take away that as a barrier. I think that can be quite powerful to empower people to do what they really want to do. 

William: 

Yeah, and I agree. And Natasha, you quite rightly said, it is that wider team, in primary care who is working on this including the district nurses. And it goes even wider than that to social care as well. But I think just keeping it to the clinical side, I think it is that division of responsibility who’s best to do it in the practice. 

As you say, if it’s in the protocol, you’ll get nurses and other allied health professionals probably being a little better at it because it’s there for them to think about whereas for GPs they’ve got to recurrently think about it in their mind, and we forget. We often forget. So, I think getting it, you know, as you say, who’s best to do it in, in the practice, who’s best to be able to deliver that services so it doesn’t get forgotten. It doesn’t get pushed aside. I really you know, I’m encouraged. The fact that I think we’ve moved a long way since the kind of 90s when I got involved with this. But I think we can obviously still go for further. But it’s so lovely to hear now GPs really knowing about it. Not kind of questioning why we should do it. 

When I started the guidance was three times 20 of vigorous activity and walking and I think it was some Sec of State said that said “there’s no room for walking in health care”. They said that moderate exercise or movement was just useless and to exercise you need to get out of breath. I remember having discussions about it. So, we have definitely moved on.  

Natasha: 

I think the other thing that we need to be aware of and, really push is public education, not just through individual interactions with patients, but through health generally. And of course, so many, digital innovations like the NHS app which really could exploit those opportunities. So that people could get gentle nudges about physical activity as they collect prescriptions and as they look at their own healthcare data, so that’s a relatively easy way to start to change the importance of physical activity in patient’s minds. Because, of course, if they’re already understanding that this is a key, important part of health care, then those conversations for individuals become much easier. 

And then I suppose the other real opportunity going forward is the use of wearable data and how we can capitalise on that as health care providers.  

William: 

I do agree, I think, I mean, I often, you know, with their permission, of course, take their phone off their hands and say, right, where’s your health at? I mean, how many steps have you done? 

And then, they look at it and they can be horrified sometimes to see how many steps they’ve done per day. And it is, as you say, in people’s hands. And obviously the wearable data is going to come through. But what I always say, and I think as it comes, into the discussion, is that we shouldn’t be saying that physical activity is always an add on to your life. 

You have your life and then you have physical activity. You know, if you look at the things, this is physical activity as part of who they are, what they do, their activity, their enjoyment, their fun, it kind of defines them in their life. And therefore, we’re just saying, you know, this is making you have a better life and more enjoyable life, a fun life, as opposed to have to do this kind of, duty of doing your steps and when you’re not really enjoying it. 

So, I think that in one way the wearables are great and that they give that track. On the other hand, we don’t want that to become a technology that becomes an additional to their normal life.  

Natasha: 

Yeah, and I suppose that brings us onto the next question, which is what the practical things are we can share to enable colleagues, in health and care to join the movement. 

And we’ve already started talking about wearables for me, just taking a physical activity history can be a game changing moment in a consultation because it tells you so much about people’s attitudes, their confidence, their functional capacity, all of which feed into the whole medical situation. So, we’re not taught routinely at, medical school to take physical activity history, but we need to be, and we need to drive that through postgraduate curricula as well.  

Dan:  

I think one of the practical things that comes out when you deliver these pack sessions to healthcare professionals is actually a lot of the things that you can give them. Quite simple. So people we talked about the risk already that once you tell people and give them a resource to eat, such as the, you know, the Moving Medicine Consensus Statement around risk of physical activity and reassure them that there’s something backing them up. 

Actually, that can be quite helpful. And I think providing with the with some evidence that the permission to go ahead and say, you don’t have to do like you said, you know, half an hour of vigorous activity three times a week, but actually encouraging people to start with small steps. I think giving people that in their toolkit so that once they found out how much someone does and how they feel about physical activity, that they have the permission to go ahead and talk about things confidently. 

I think that’s when you start to see lots of people nodding and sort of taking notes and seem to really engage with things.  

William: 

Well, I agree, I think, I think there are tools out there to really help you understand how to get a patient moving in the motivational interviewing type of scenario, where you start, where the person is and you kind of encourage them from where they are. 

Because most people think they’re not the sporty type, they’re not activity people. They’re it still comes across like that. And I know some enthusiastic GPs that can’t understand and get frustrated when someone doesn’t kind of comply with what they’re trying to say. And we start where someone is. We encourage them that they and just do a little bit more. 

And it is that simple. It’s just getting them forward. I do agree, Natasha. I think that physical activity history is important because it helps you understand where that patient is and what their perceptions are of activity. And sometimes, you know, they may have some you know, false perceptions that have gone back for years and years to stop them. 

But you won’t know that until you’ve talked to them about it. And, you know, it takes a bit of time, but once you’ve got that, you can then build on it for the rest of your consultations and make sure that they get there. And I think at two parts that we really need to do, I do find that helping the patient understand the science behind it, that, yeah, everyone knows it’s good for you, but they don’t quite know why. 

And just explaining the simplicity of it, how it helps the brain and the immune system and things like that helps them to realise this is a real thing for science. And it’s not me just sort of saying, because I’m just being a bit judgy on you. But there’s some real evidence and science behind it, and it doesn’t take a huge amount to get those benefits. 

We don’t have to do as you say, all those marathons or running or anything like that. They just need to get moving. And it’s the sedentary behaviour that’s the damage. And I think that’s the other way of putting it, is that if you just sit there, you are going to get overheated mitochondria, as I tend to call it, and they get you it. 

And they kind of see they get that and then you build them up from that. And it’s getting that science, getting evidence, getting that importance and then just starting where they are. And I think we’ve again learned a lot in the last few years about how to get motivational interviewing and then into a quick practice. 

Natasha: 

 Yeah, as Dan said, the Moving Medicine Healthcare professional resources really help people understand how to have a motivating conversation in the context of many long term conditions and gives loads of information about the concerns the people have, the benefits of physical activity, all the difficult questions that that, people may not know the immediate answer to. So, Dan, you’ve done a huge amount of face-to-face education through the physical activity clinical champion resources, haven’t you? And I think you’ve written some of the resources as well. So, I know that you’ve been really involved in that programme.  

Dan: 

Yeah, absolutely. I mean I think the first thing is it’s always a really rewarding thing to go and do. You get to go and meet lots of different healthcare professionals working in lots of different kind of quite interesting areas. 

And there’s often a question that comes up from someone who’s doing some sort of healthcare you had no idea really existed. It makes you think about how you can help them think about getting more physical activity into their practice. I guess for those who aren’t aware, the Physical Activity Clinical Champions scheme is, essentially where a trained educator can come into wherever you’re working and provide quite flexibly, education and physical activity. 

And that could be kind of a short half hour session, often around an hour, could be longer, and they can be a general teaching session or more tailored to specific kind of conditions. And, I think it’s often received really well. I think that you do often starts off with people who sometimes people are asked to come to the department and aren’t sure about how it’ll fit in. 

And, and normally over the session, you can start to see a degree of scepticism disappearing. And as I said, it’s often when you’re helping people see it actually, how it can help their patients. And you share that scientific background with them. You share actually what they need to help patients do and how they can do it. You start to see, you know, more people nodding along and more people taking notes. 

And I think what can also be helpful is you have to dispel some myths. So around for instance, if people have to do 10,000 steps a day, which we know for some people is great and they enjoy doing that. And for some people it’s not achievable or helpful. You can also see people turning up in activewear or who may be more active themselves and thinking about, well, they reflect on their own experiences and seeing how they can build that into their own practice. 

And I try and encourage them to think about, you know, not telling people if you’re running marathons, you need to be running marathons, but it’s helping to think, well, if you have an experience in it, how can you, in the context of the patient, reflect it with them and bring that into your practice? I think people often aren’t. 

And so, the feedback is generally really good, and people are always very keen to get the slide sets because I think they find a useful resource to have outside of the teaching session as well, so that they’ve got something to refer back to. They’ve got those bits of science and those facts that they can share with patients, as you mentioned, William. 

William: 

What we haven’t talked about so much is secondary care. And I think that’s an important area. Where do you see the sessions heading, and why has it been neglected for so long, that physical activity hasn’t been and put into secondary care. And how is Moving Medicine going to help that?   

Natasha: 

I always worry about saying things neglected because I see some incredible areas of practice, practice in the hospital that I work in in Oxford, but also across the country from people who are working across health care pathways, and really trying to embed physical activity. And I’ve seen that in cancer pathways, I’ve seen it in amputee pathways, I’ve seen it in mental health pathways, seen in acute medical pathways. I’ve seen some really fantastic initiatives over the years. But I think that the real problem is that it isn’t consistent across the board. So, for many pathways, it still isn’t seen as a necessity of as of care. So, we delivered what we call the active hospital pilot. Started it started in Oxford and then spread out to several other trusts across the country. 

And through that resource, which sits on the Moving Medicine website, we have multiple examples of how you can embed physical activity easily into your health care pathway, and including lots of tangible resources like patient information leaflets, those sorts of things which really help people decide how they’re going to do a quality improvement projects of their own. So I think there are, massive opportunities within the secondary care setting in inpatient, but also in outpatients. 

And there are initiatives which are growing, which I think will help, embed this better. But as I said earlier, I do think there needs to be some contractual changes for providers to help at an organisational level, understand that this is important, and then support staff to do the work that they often really want to do.  

William 

Yeah, I think that contractual side is really important. And I think going from the active hospitals to the pack, which is a physical activity, clinical champions. So, as you know, we’ve been working on this together with the University of Sheffield. That is really just to ensure knowledge is passed down to the internal clinical team in primary care. And often it’s, you know, as Danny said, it’s been very well received. 

But I think we’re going to really try and get this into a place-based work now as well. So it’s all very well sometimes just giving clinicians the knowledge about the physical activity. But what we really want to do is to then make sure that that pass is down to where the patient in their life is, which is outside in the community, which is why social prescribing is so important that we get that pathway completely clear that anyone who’s a link worker, who one of the people that is a GP or nurse can refer to, who then sits down with the patient to work out how they can to, you know, use the community effort or meeting up in groups or physical activity or walking groups, whatever it is, to make it really come to life. And I think that is now starting to really develop in places like in Oxfordshire and in Sheffield and Birmingham, where it’s very much place based. So we get that continuity from the clinician through to the link worker down into the community. 

And so physical activity becomes real. So, it’s not just them having to do the steps, but it actually is them doing a dance class or a walking group or conservation work or doing some other work, which makes it really exciting. And I think that’s certainly what the PAC model (Physical Activity Clinical Champions training. It is part of the Moving Medicines programme https://movingmedicine.ac.uk/) is doing. And hopefully that’s going to spread across.  

And, and I’ll just mention the other thing is the e-learning, which sits alongside this BMJ have been having out with nine modules. They’re adding 1 or 2 more about physical activity. Again, it all connects with Moving Medicine, all coming from the same hymn book, really the same script. But it’s just for clinicians to be able to understand, do some, get their points as well from the CPD, to be able to get the e-learning in and that’s in the outside. 

That’s outside the paywall of the BMJ, there is also for e-learning for health have got one as well. So, I mean it’s just shows there’s a huge amount of resources now that we can use, from removing medicine to the e-learning to the pack and then obviously the moving the active hospitals and then the kind of a last bit is that we need to get it back into the medical students as well into that. 

I think that’s the last bit we just need to really do. And I don’t know if there’s any other parts you’d like to mention. Dan, on, on. How do we make that the whole now rather than some missing bits?  

Natasha: 

And I completely agree with you, William, about the importance of undergraduate education, not just for medical students, but for nursing students as well. 

As we know, the undergraduate curriculum usually overcrowded, but prevention is one of these three key areas, that are highlighted in the ten-year plan. So really, we can’t talk about prevention anymore without talking about physical activity. So, I think it’s a more and more compelling priority for the universities going forward. 

Dan: 

 I think you’re right. It’s about putting everything together so that physical activity is is part of everything we do. 

Not an add on the people who are really interested might do. I think you right. Having those place-based approaches so that there’s a whole network and infrastructure in place is beneficial. And starting at an undergraduate is a great idea, because it means that it’s just something that people know they do from the start of the time, that they start learning how to do their jobs, rather than something that’s added later, or you have to go see a specialist to do so. 

I think the more and more we can do that and integrate it, everything we do, the more successful will be.  

William: 

I think that and I think one thing that you’ve done really well for me from, FCM is to have that one consistency that goes across everything so that we don’t get the contradictions and sometimes inconsistencies in the advice we’re giving. 

And I think having that consistency of one kind of origin to, and disseminating it right out is really helped clarify the message so that whoever you are in the system, you know, when you were in the hospital as or whether you in primary care or the community, you’re getting the same message, the same origin, the same evidence, and therefore the same kind of consistency to make sure that we’re all following the same thing and that I think it’s really helped clear up some of the muddle that has happened before. 

And it is a simple message in a lot of it. As you say, there are some specialist areas, but the great message, if we can get that real consisting of moving more, starting where the patient is, it’s not going to be harmful, then I think the progress is going to be fantastic. And I did go to I had my, anniversary. 

I won’t say which anniversary it was at medical school because it makes me age. But the new dean there was saying when I mentioned what I was doing and he said, we’re now in our medical school. We’re looking at what do people use in their clinical lives for the rest of our clinical lives? And we’re going to get rid of some of the stuff that actually made no difference at all to their clinical life. 

But one of the things we absolutely have to put in is diet and physical activity. And this is at the London Hospital, the Royal London and Barts and UMC. And so that is the one of the drives. It’s great. So, it is getting there. It is being realised without even a prompt from us that the medical schools are really thinking it through.  

Natasha: 

Well, that’s good to hear. And I can’t leave this podcast without, thanking Sports England generally who have made that consistency possible through funding programmes like pack and moving medicine, the actual hospitals and so on, and the learning resources, they, they through there. The initiatives over the last ten years have really transformed the, the picture for the UK, and we now have global influence, because of that. 

So I just want to thank them for their ongoing support in this in this area and the incredible people who work there. I totally agree. In session, I think the other, you know, absolutely thanking their leadership because they got this going in the start with but also the enthusiasm of so many people who came on board, everyone in the background, some of them doing it just voluntarily because they felt it was important.  

William: 

I mean, I think we’ve seen, you know, if it was ever described a movement. This has generated a movement within a campaign, if we can, to pull the two together. So the momentum is definitely there now. And, and it’s really exciting. Natasha, thank you so much. We we’ve moved a long way. There’s still a long way to go, but I think we can only come across and hopefully people listening to this is how encouraging it is, but also how we still need to really make sure this is embedded. 

So we don’t need to have these conversations again. It will all be there in every single pathway, and that’d be those contractual arrangements which Natasha you’ve said is so important to make sure it says so. Thank you for putting this on.

Thank you for listening to the For Ways Forward podcast produced by NHS horizons for NHS England.