https://soundcloud.com/nhsengland/the-four-ways-forward-embedding-physical-activity-at-the-heart-of-community-centred-care-and-prevention

Introducing the Four Ways Forward: A conversation with Sarah Price, Director for Public Health, NHS England and Sasha Karakusevic, Chair for Public Health, NHS Horizons

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. 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.”

Sasha Karakusevic, Chair for Public Health, NHS Horizons:

Hello, I’m Sasha Karakusevic and a member of the team at NHS horizons. Really good to be with you today. Sarah, would you like to say hello?

Sarah Price, Director of Public Health, NHS England: Yeah. Hello, everyone. I’m Sarah Price. I’m the director of public health at NHS England and really excited to talk about, physical activity in the context of the NHS.

Sasha Karakusevic: Thank you, Sarah. It’s great to have everybody with us. This is episode one in a series of four podcasts all about physical activity and movement and how it can help us all, in our health and wellbeing. It’s coming from an initiative called the Four Ways Forward. Sarah, in a nutshell, can you tell us a little bit about the Four Ways Forward?

Sarah Price: So, this is about how we get ourselves organised in the NHS to really focus on physical activity. And we think there are roughly four areas that we really need to concentrate on. So, the first one is really giving those frontline staff the real, kind of information, the detail of how they can really use their relationships with their patients to raise the issue of physical activity and how they can improve that.

So that’s the first one. It’s a bit of myth busting in there about what you can do and what you can’t do when you’ve got a long-term condition, for example. So really important stuff.

The second one is around clinical pathways. So that’s how we organise ourselves isn’t it. In the NHS, we look at pathways from start to finish how people come into the NHS, what treatment they have and then, how we make sure we discharge them at the end of that.

Physical activity is an important part of that pathway in many, many areas. I think, Sport England has done a fantastic piece of work that reviewed all the pathways that NICE approve, and physical activity turns up in 98 of them. So, it’s a really big area and we want to pick the most important ones out of that list, something like stroke or other cardiovascular illnesses. And really make sure that that, clinicians know, what part physical activity can play in that.

The third one is around the staff. We employ 1.5 million people in this country with the biggest employer in England. And so therefore we should be, making sure that we’re doing the right thing by our staff and supporting them to be more physically active.

And then the fourth way forward is around innovation. How can we change things? What can we do differently to make physical activity at the heart of everything that we want for our patients and for our staff?

Sasha: That’s fantastic. Sarah. We’ll talk a little bit more in detail. But before we do that, what sort of physical activity and movement do you get involved in?

Sarah: So, I have to say, I’m glad no one can see me doing it, but every morning I am in my kitchen at 6:30 with, Joe Wicks and, I’ve been doing it. I started doing it during the pandemic because obviously we weren’t going out. So I was, I joined up and I’m doing it online, but it’s become such an important part of my life. I don’t feel right unless I’ve done it before I come to work. So today I was doing strength training with weights, but sometimes it’s more cardiovascular.  I’ve got a little, set of weights in the kitchen, and I, get my mat out and do it every morning, and it makes me feel set up for the day I have to say.

Sasha: Wow. That’s, That’s impressive. I’m lucky to live in, Devon and, my start of the day is taking the dog for a walk and, getting out in the countryside as much as possible, we all we all love gardening. And I think this is the point about, physical activity and movement. There are lots of different ways that, people can get involved.

Sarah: Yeah, absolutely. And I have to say, I mean, doing one kind of activity, you know, won’t necessarily. So, all your aches and pains and all your, needs out. So, being able to do different range of things, like gardening, someone I think someone said, didn’t they, that doing housework is just as good as doing a workout.

So, maybe we should all be taking a little bit more of that. I have to say, it’s not my favourite activity, but you know, all counts too. Moving. And that’s the most important thing.

Sasha: Absolutely. So, for ways, forward have been, developing for a while. Can you tell us a little bit about the, the background and how, how we got to this point?

Sarah: So, I think most people, if you ask them, who work in the NHS, would say that physical activity is an important thing. You know, everyone knows that, but it’s how do you then make that the reality? And how do you empower staff to feel able to advise patients about physical activity? And there’s lots of fantastic resources, Moving Medicine and other things that really help.

But, I mean, I think one of the challenges is that everyone’s got lots of things to do. And so, we really need to give people their script on, you know, what they could be doing. And I think partners like Sport England or Active Partnership, their active partnerships or UK Active or Richmond Group of charities, they, they want to work with this, but they’re not quite sure and they’re getting a different message whoever they speak to.

So, this piece of work aims to make sure that we all had a single narrative across the NHS about what, physical activity should be, for us and therefore how we can work with others. So, we started to have those conversations. And, Sasha, you were a key part of that, helping to facilitate across, NHS England and with partners.

Some of the conversations we needed to have to really pin down what we wanted to emphasise to our staff.

Sasha: Thank you, Sarah. And as you say, we’ve been involved and it’s been an interesting piece of work because, we’ve had to combine national evidence, lots of different groups, the, the collaborative groups. Now I’ve got 26 member organisations and, a huge place-based agenda.

So, tailoring all this work to be relevant, wherever people are.  We feel like we’ve made a lot of progress, but there’s also lots more to do. Could you, maybe tell us a little bit about how you see the next phase of work, getting Sarah for each of the four ways forward?

Sarah: So, having got it all signed off and agreed now, which is great. We need to make it a reality, and we need to think about the implementation. So, taking each of those areas, we’re trying to think through what the implementation plan should be and where we’re going to start. I mean, I think it’s really important that we don’t try to bite off more than we can chew.

But working with partners, how can together we come up with a really, comprehensive approach in each of those areas. So, in terms of empowering health and care professionals, and what do we mean by that? I think, you know, I talked at the beginning about, how important it is to give our frontline staff the tools they need to be able to really talk to their patients about how important physical activity is.

So, whether that’s scripts and there’s lots of information available. But also maybe some training, about how they can get those messages across and motivate patients to really, take that forward. And then there’s an element of myth busting. And again, I mentioned that at the top, but I think, you know, there is a view that you must have medical sign off before you can do any physical activity.

And that’s particularly problematic for our primary care colleagues, where they’re seeing lots of people say, oh, well I need to have you check me out before I can go walking or whether I can do this particular class. And the evidence is that you don’t need that kind of sign off. So, we really want to say to both patients and to, our staff that, that these aren’t things you need to worry about, that moving is so important.

So, giving people tools and, doing some of that myth busting. So, the second one around integrating physical activity into clinical pathways. We know that it should be part of the treatment, and it should be an active, no pun intended, part of the treatment, but sometimes it gets a bit lost. And again, it’s partly overlapping with the first one around giving people the tools, but it’s also round and being very clear about where in the pathway physical activity comes in.

There’s some fantastic work being done, with our colleagues in Greater Manchester, for example, around, doing physical activity. Before you have your cancer treatment and showing real improvement in recovery and, and metastatic spread. And so, you know, we need to be able to provide that help and support.

So, making sure that physical activities ready for that. And then in terms of the workforce, we’ve got lots of, options for our staff around things like bike loans or, reduced, membership for gyms and things like that all important. But again, we need to make sure people understand that they can build into their working day.

And if you’re working shifts, it can be more difficult for active travel. How do you get to work? How do you get home again? Whether or not we encourage people to have walking meetings or to use their lunch breaks to perhaps go off and do a class. So, there’s lots of things that we can do to make, physical activity as part of everybody’s day.

And then innovation. Innovation is, is, you know, we’ve got lots of ideas about the sorts of things that might make a difference. We need to work with partners to test those out, and we need to evaluate them, to know what works and what makes a difference.

Sasha: That’s brilliant. And we know, since you started to talk with people, the Four Ways Forward have really captured people’s imaginations.

And in the Horizons team, we’ve been struck by how much work is already happening, are there any things that you’re seeing that, feel important, for people to take note of?

Sarah: I mean, importantly, people are approaching it. Since we’ve published the full way forward, people are saying, well, we’d like to get involved and we’d like you to help us to think about this.

So, taking one of the clinical pathways, the, stroke teams have approached with the clinical lead for stroke, because they see that when people have, transient ischemic attacks and they come into a clinic. So that’s a, well, sometimes it’s called a mini stroke. And is a real, warning that you are at risk of having a full-blown stroke, a disabling stroke.

We diagnose that, and we put people on the right medication. But at that point, a real opportunity to get people to be more active to help prevent that disabling stroke. And really, we need to be making sure that people have got the tools to be able to do that. So that’s an example of where we’re starting to, really emphasise the importance of physical activity.

Sasha: You touched on, the work of the faculty. And in podcast two, Natasha Jones will be talking about the work, that they’re doing to de-medicalise referral and Hussain Al Zubaidi, the Royal College of General Practitioners lifestyle and physical activity lead will be talking about how that works in practice. So, lots more to come in our forthcoming sessions. Now, we always talk about the positives, but can you see any problems that people may need help with to implement the four ways forward?

Sarah: I think we do need to provide people with some of the evidence and some of the tools that they can use. And, you know, the example you’ve just talked about, what can you tell a patient if you’ve only got a minute, what can you tell a patient if you’ve got five minutes? You know, those types of things are really helpful to people and will make it part of everyday action.

And if we had lots of money, wouldn’t it be fabulous? We could do even more than we’re already doing. But some of it’s about trying to readjust the work that we already do to include physical activity. So, it’s not always about money, but, you know, if we had a bit more, it would be even better than it is.

So, there are challenges, nonetheless. But I think working together and developing the partnership that we’ve got, across both the NHS and DHSC and with all those, great partners out there, we can make a difference. And it was really nice to see that recognised in the NHS ten-year plan, wasn’t it, that, no one party can pull this off?

Sasha: It’s got to be us all working together. So, just before we say a few words about the other podcasts, Sarah, to wrap up, what would you ask people to pay particular attention to as they work through the Four Ways Forward?

Sarah: So just to start thinking about how they can help and support you to do whatever it is you do, in your day-to-day work. And how you can support patients to be able to be more physically active, and if you got any ideas, we’d really like to hear them.

Sasha: That’s fantastic. So, just, remains for me to say thank you, Sarah, for introducing the Four Ways Forward. We have three further podcasts coming up, and you can see all the details on the NHS England Four Ways Forward landing page.

And we look forward to working with you, to implement all this excellent work. Thank you very much. Thank you for listening to the Four Ways Forward podcast produced by NHS Horizons for NHS England.

Podcast 2

Equipping healthcare professionals to have the skills and confidence to prescribe physical activity: 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  

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. You can listen to all episodes in the series by visiting England dot NHS stuck and searching the words for ways forward.

Podcast 3

Movement Matters: Why Supporting Physical Activity in NHS Staff is Good for Everyone

A conversation with Tara Dillon, CEO of sense for the Chartered Institute for the management Sport and Physical Activity; Hayley Lever, CEO of the Greater Manchester Moving Active Partnership and Hussain Al Zubaidi, RCGP Lifestyle and Physical activity lead

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. A podcast where we hear from health experts on the importance of movement for our health and the health of the NHS.

Tara Dillon, CEO of sense for the Chartered Institute for the management Sport and Physical Activity: Hello and welcome to this podcast one in a series of podcasts designed to support healthcare professionals and empower you in understanding your role in four ways forward. Welcome and thanks for joining. So today’s podcast is discussing the importance of being physically active and moving more and specifically how important that is for you both personally but also professionally and improving better patient outcomes.

So you couldn’t get two better experts to talk about this subject if we tried. So welcome to our guest speakers, Dr Hussain, who is a lifestyle doctor, he’s also the RCGP Lifestyle and Physical activity lead. And is occasionally, as seen on TV, a bit of a celeb.

Dr Hussain Al Zubaidi, RCGP Lifestyle and Physical activity lead: Thanks for doing this today. Thank you for having me, Tara.

Tara: We also have the brilliant Hayley Lever who is the CEO of the Greater Manchester Moving Active Partnership, who, worked tirelessly over the is getting the people of Manchester moving more and, initiating some brilliant initiatives on integrating physical activity and health. Welcome, Hayley.

And my name is Tara Dillon. You’re probably wondering, you know, I was, I’m the CEO of sense for the Chartered Institute for the management Sport and Physical Activity. So we’re the professional body for the physical activity workforce. I’ve been in the sector for 38 years, and I’ve seen first-hand the power of physical activity integrated into health.

And I’m really looking forward to sharing some of those stories with, the guest speakers today. So why is physical activity so important? If I, if I were to quote an NHS CEO, so to speak, at a conference a few years ago, he said, I’m coming to, you know, he’s saying he said that if physical activity were a pill, it would and should out-sell all pharma products, which I thought was a brilliant quote, and I’ve hung off that for quite some years. So you say, where is the evidence and impact of the importance of physical activity?

Hussain: Thank you, Tara. And I suspect, he or she was very much correct because, you know, when we look at physical activity, one of the key stand out things is the breadth of impacts that you have.

It’s not just specific few conditions where we know that both increasing activity levels and reducing sedentary time has benefit. But it’s over to 21, 22 different chronic conditions. And so that can really be its strength because you may be using physical activity to improve your mental health. But at the same time, you’re having compound benefits improving your joint health, your skin health, also improving your cardiovascular health and spiritual health.

It just seeps into so many different areas. And just to give you some sort of key standouts, if you think about some of the key conditions that we’re currently, tackling within the health service, we know that regular movement can cut the risk of chronic diseases like type two diabetes and cardiovascular illness by up to 30%, and it’s linked with a 20% reduction in all-cause mortality.

So the term all-cause mortality is essentially the risk of dying from any cause. And so that’s really significant. And you’ll be hard pressed to find a procedure, injection or pill that will have those kind of results. And beyond physical health, we know physical activity is a proven antidepressant. So if we compare it directly against, antidepressants and we look at, for example, doses of, of 75 minutes across a whole week, we know that reduces your risk of depression by 18%.

And we’ve looked and we know that there are some aspects we understand in terms of the release of chemicals like endocannabinoids, as well as endorphins and endogenous opioids. The actuals of your body are generating painkillers itself. That’s where we see its benefits when it comes to mental health, as well as chronic pain and all of these gains, they don’t just happen in isolation.

You know, when we model an active lifestyle ourselves, you know, our credibility in advising this to patients is through the roof. And, you know, studies have shown that healthcare professionals that are able to maintain a healthy level of physical activity are far more likely to be effective, inspiring and encouraging their patients to take on more physical activity.

Tara: That’s great. He’s saying brilliant. Thank you so much. I mean, the evidence is overwhelming, right? So what if we can tackle dispelling some of the myths a bit here? Because what you’ve just outlined is extraordinary, right? The power of it, the power of physical activity and some people who will be listening to this will be thinking, well, I just don’t know how.

Well, what do I access, you know, how do I suddenly, as a healthcare professional who doesn’t really move very much because I’m a busy person and I have commitments and all the rest of it, I’m going to have to join a gym They’re fantastic places, but that’s not the only place to become physically active.

I tell people to take the dog for a walk even if they haven’t got a dog. I mean the power and impact of that. If you haven’t been active is extraordinary. I hope we dispel the myths and I and also say, you know, think some healthcare professionals are really quite, nervous about prescribing movement and activity, particularly in cardiac patients, for example, you know, there’s this fear that if I refer you to a sports club or a gym or just to go for a walk, you might suddenly have a serious cardiac event. What would what would you advise healthcare professionals in that respect?

Hussain: Yeah, really good set of questions there. You know, starting off in terms of starting their own journey, I would say it’s actually the best place for them to consider kind of what they can do. If they do feel like they aren’t getting as much movement as they’d like, or maybe as much as what is recommended by the chief medical officers physical activity guidelines, then that’s sort of the best place to start when it even comes to supporting your patient, because at the end of the day, we want to be able to encourage and have conversations with our patients that we’ve also had to navigate.

Just speaking from my own personal experience, you know, having those discussions with myself and seeking support and advice from those around me to increase my activity levels from what was very sedentary. It helped teach me the kind of sort of tools that I would need to start that journey. And sometimes we miss a few steps, and we jump along the line to where we want to get, rather than thinking about what the steps and stages I need to go through to improve my confidence, knowledge and skills around movement.

And so I’d highly recommend people look beyond what is sometimes glamorized as a sort of ideal movement. Let’s say completing a marathon or, you know, going to the gym or whatever has been kind of idolised as sort of the perfect movement to just consider how moving the body makes them feel. Because often when you’re starting off, there’ll be some movements that you don’t like that feel difficult, that lead to a lot of fatigue that you then struggle to balance up, but that your other, commitments.

But then there be other movements that actually do the opposite, maybe the lighter or shorter. Maybe they involve music, for example, dancing or community or being outside in nature, which you love. And so try to make that sort of first step in getting more active, as desirable as possible, often speak to my patients. And I say, if you don’t feel 6 or 7 out of ten at least confident that you will maintain this movement going forwards, then it’s not the right thing to try and tackle.

Like you said, we need to adapt it. We need to think about it differently. Just to give you an example, you know, had one patient that wanted to start walking more, but very much didn’t enjoy doing it on their own, and they were quite isolated. Unfortunately, the wife died a few years previously and they just didn’t feel connected any more with the community.

So he didn’t get motivated walking on his own. But then he also struggled with not having a close network that he could reach out to go on walks. And so we I encouraged him to go to Park Walk. So, the same events that happened at Park Run, where you can walk at these things, and he’s been able to develop a community because he volunteers as the park walker.

So he gets to talk and integrate with other people, his community, who he then goes on walks at other points in the week. And so it’s just thinking about whether it’s yourself or the patient or colleague that’s working in health care as well. How can you reduce the friction, the first bit of movement and decide based on your preferences and needs rather than what you think is kind of ideal?

Tara: So I mentioned, at the beginning Four Ways Forward. This is NHS England’s but around integrating physical activity and wellbeing. Obviously there are four ways forward. The first one is about empowering healthcare professionals. The second one is we’ve touched on integrating physical activity into clinical pathways, which I think we’ll come on to shortly, but also supporting the NHS workforce.

An innovating through partnership, you know, so, Hayley, how do we support NHS staff in that journey to wellness? Because as I said earlier, if a health care professional suggests that movement is good for a patient, the impact is enormous.

Hayley ever, CEO of the Greater Manchester Moving Active Partnership: Where my mind’s going to is back in, the pandemic, actually, when we were talking to our role here is to support and lead and connect people within Greater Manchester, within our place.

And back in the pandemic, we were developing the new data moving strategy online. Everything was online. And it came about kind of by accident. And we started with a question to reach, you know, to each room, which was how does movement matter to you for your family in your work? And, and that very, very simple question, which was supposed to be a warm up, just to get people connecting in the room and in breakout rooms became the absolute foundational questions for everything we’ve done since. What was very striking during that period is that it didn’t matter who people were, which sector they were from, what their role was. Everybody could access that question. How does movement matter to you, your family, your community, your work? And so building that conversation from the ground up was really important to help us understand how we best support people to play their role.

We’ve had, the benefit of valuation research is embedded in this work, over the years. And one of the things that’s really quite striking is that when someone’s got a personal belief in the importance of movement, then they’re more likely to feel confident in advocating that for this. But we have to support them because they might be a clinician or somebody working in the health system who’s a massive advocate and champion of this, but they can’t connect to someone that then, you know, and they haven’t got the tools to have conversations that connect and understand the person that they’re meeting with.

You know, it’s important that, our work is to develop that belief in people, support people to have a meaningful relationship, a positive relationship with movement, physical activity themselves such that they can support others in terms of sort of how you how you help that happen at scale. It’s about telling stories and sustains them so beautifully.

Is that what then? That’s what spreads and grows.

Tara: 100% agree. It it’s a cultural shift, right? This this mindset is key. I mentioned earlier about gyms and, sports clubs and stuff like that. But just from my perspective. But some people I speak to in, in health care are sometimes a bit nervous about referring a patient or advising a patient to join a gym or a club because they’re not quite sure how qualified the physical activity professional is.

So I think it’s probably my job to dispel that myth. You know, the physical activity workforce is around 600,000 people working in the physical activity workforce. But the size of the motor trade, it’s very well established. And in sport, you know, there’s about 3 million volunteers. You know, there’s it is a huge, huge workforce.

And as the CEO of the professional body for, for the workforce, you know, just wanted to give some assurance to the listeners in the podcast today is that we’re actually set up a bit like your Royal Colleges set up in the same way that RCGP is or RCN. And insofar as we have professional standards and the professional body, the Chartered Institute is the custodian of those standards. So it talks about the minimum knowledge, skills and behaviours required to be a coach, a lifestyle coach or a personal trainer. Gym group, sports coach, etc. they’re very robust. They’re delivered by quality insured training provider partners. And individuals become members of the professional body. They can gain chartered status. So you can be absolutely assured of the professionalism of the incredible physical activity workforce.

I think what we’ll talk about in a second is this we’ll get some anecdotes, we’ll get some case study, you know, where we know it works. I was talking to a friend of mine at the weekend who works in a in a in a breast clinic in a in a local hospital. And it’s just brilliant to hear and see that physical activity is being used, really powerfully in, in rehab and pre rehabilitation.

So pre having cancer patients for example do you have any case studies you can share in that respect?

Hussain: Yeah, like so many case studies of where, you know movement and physical activity have improved health and it often improves things that the patient had no idea was, something that it could potentially do. And I’ll use one example.

I’ll change his name, obviously just for anonymity, but let’s take Paul. And Paul was a gentleman that when I first met him, he was about 8 or 9 weeks post discharged from hospital. This was during the right, in the sense of the Covid pandemic, where he was in ICU for a number of weeks, and in fact, his family were told that at one point, highly likely he was not going to make it is absolutely heartbreaking.

But he came to my consultation room, and he said they mentioned that one of the reasons why I developed such a severe response in reaction to Covid was, unfortunately, my background, health, you know, he was struggling significantly with his weight. His Cardiorespiratory fitness was very poor, unfortunately, and he wanted to have a discussion about how we can go about changing that.

And I’ll be totally honest, you know, when I was first thinking and going about this, I still felt relatively overwhelmed with the task at hand because there were a number of issues and barriers and problems in the way and I was slightly sort of, what do I do first? Where do we go? The tip that I learned from that experience, which is the healthcare professional, does not need to have the answers.

You do not need to provide the exact plan by which he’s going to mastermind this turnaround in his lifestyle and health, instead of just giving generic advice to Paul in this case, you need to focus on how can we create an environment in this consultation over a short space of time, over the next few minutes, where you can empower the patient to start feeling confident in generating their own ideas and plans, and you can make them feel good about it, and you can help them realise what those changes that they want to make is going to affect their health.

So I quickly switched it ranks. I had no idea what Paul should be doing first if I was being honest. I said, Paul, you know, what do you think? Where do you think we should go from here? And he started talking about different things that he wanted to try, and he’d highlight why they hadn’t worked in the past.

And, and he mentioned that because of his weight, his joints always hurt very significantly suffered with osteoarthritis due to that. And we talked and it sort of the conversation eventually just steered to swimming. And he felt that, you know, and swam for over 20 years. But when he did swim last, which was over in university, he actually really enjoyed it.

So, we discussed the local swimming group that occurs at the Everyone Active gym near us, where they allow patients with long term conditions to access the pool for free for 12 weeks, and then after that, they have 12 weeks at reduced membership, called the social prescribing membership, and then they go on to full membership after that. And that was the beginning of his journey, and he started swimming.

And it took a bit of time. And eventually that swimming, he got more confident. His breathing starts to improve. He started walking with us and many months and years down the line, he was making significant progress. And in fact, one of the things that we often do is we track our patient’s activity to keep them motivated on an app called Strava.

And I notice on Paul’s Strava that he was starting to do a lot of walks in Leeds. I’m based in Leamington and that’s over two hours away and I like the next walk. I said, Paul, yeah, I noticed that you’re in Leeds a lot and he goes, yeah, I moved to Leeds about nine months ago and I was like, what do you mean you’ve moved to Leeds?

So you’ve been coming to the walk and the swim like every week for the last, you know, two years. And he goes, yeah, I kept coming because yes, my health is improving. Yes. My weight was dropping. Yes, my breathing’s better. But the benefit I got most out of physical activity was the friends I made and the confidence they gave me.

You know, I started having conversations at work, telling them what I needed in order to live a happy and healthier life. I started having better conversations with my family, and they understand me better and I understand them better. I’ve got a much better relationship with my daughter. The benefits he valued most were the things that made him feel better, that made him think he was a better dad and a better employee.

And that is the key message that I want to get across there is that movement is not this simple thing that makes your heart pump faster and you’re breathing better. It has benefits across the board.

Tara: Yeah. What a fantastic case study done. Who said. And I think a lot of people, will understand the benefits. But many people, particularly in the, in the professional world, like to know about evaluation and research.

And do you have any case studies you can share with us on research and evaluation? Because I know you guys have done quite a bit.

Hayley: Yeah. I mean, there’s a lot I think what I’m struck by is and this is very much of improvement over the last few years is that we have got collectively, we have got evidence and research and evaluation to help us understand all of this.

You know, in terms of why does it matter what works, how do you do it? You know, what’s important and how you do it. So I think in this moment it feels like we’ve got we’ve got great evidence. What we really need to understand is what’s the real question that someone’s asking and needs to understand. Who is it for?

So this is a strategic, you know, I need to make the case at my health board. You know, or is it? I need to be able to support an individual who’s sitting in front of me to understand the evidence base and it goes back to story and translation. I think, for me is understanding the evidence and evaluate, you know, the evidence that’s available to us and then working out how to connect that and how to use it well to support the work.

And the evidence and evaluation and learning at an individual level, right up to a national level now and everything in between, you know, so we can explore what matters in terms of language, what matters in terms of how we go about things. It can help people to understand the return on investment or what they might commission, or how they might deliver a project or a programme.

It might help to, support and influence in government to understand at a governmental level what are the conditions that we need to create around this work? The, the skill is in is in that connecting between what is the actual question, what’s the problem I’m trying to solve here? And then which data, which evidence, which research is going to help me to, to develop, you know, whether it’s making the case or helping some to understand or whether it’s helping someone to do that job in the neighbourhoods, our job is very much in that kind of connecting, translating thing.

Tara: I would imagine there’s a lot of people listening today who work in health care. Probably sat there thinking, I too want to feel the benefits of that. I would like my mental well-being to be better and be part of a community, and do something with people that are like minded, rather than go out there on my own and try and do it.

But there’s there are other tools as well. Aren’t that who’s saying that that couldn’t support the NHS workforce, but more familiar to the NHS and not so much on the physical activity side. What’s available to people?

Hussain: Yeah, there’s a lot more information and tools, for example, digital tools out there, which is making the job of encouraging physical activity for patients easier, in my view, and more effective.

So, if we think about the NHS active ten app, this helps to really break down and sort of chunk up and explain what and why we have that of 150 minutes per week guideline. And of course, there’s, you know, well-known guides and apps like couch to five K. But for those that do want to take on running, we have things like Couch to Fitness, which is a Sport England funded program by the Our parks group, which has a number of different ways of getting active, whether it be outside the window.

So these can be good to help build encouragement and help people progress. Now clinicians can use these tools by either signposting or directly, you know, engaging patients through them and showing them kind of how they work. And also, let’s not underestimate the power that these apps have in motivating people. But we also have more and more useful resources out there for patients.

And for example, We Are Undefeatable, which is a campaign set up by the Richmond Group of health charities in the UK. They have resources for both healthcare professionals and patients, and it’s definitely my go-to, whether it comes to having displays within the waiting room at Primary Care Center to having resources that clinicians can either text out or print off to give to patients, these can help us.

They can give us that structure and confidence when it comes to discussing these kinds of things. And more and more now we’re seeing healthcare professionals being empowered through education. So there’s more resources out there. For example, the Royal College has developed for GPS is a framework for those to build experience and training in the role of lifestyle medicine, of which physical activity is a key pillar of.

So we’re seeing training being delivered to equip them with that knowledge. And then hopefully with time we’ll see confidence increase. Because what we’ve seen from some of the work that we are undefeatable have done is that patients really value healthcare professionals’ opinion and advice when it comes to physical activity. But unfortunately, the healthcare professionals don’t always feel confident and empowered to have those discussions.

So we’re hoping that whether it be training, whether it be resources, tools and also key statements like this, you know, the Four Ways Forward here for harnessing the benefits of physical activity. This can be all part of the process where we can see that shift of incorporating more physical activity, conversations and discussions within healthcare consultations.

Tara: Just quickly also – what’s the RCGP, Physical Activity Charter?

Hussain: The Royal College of GP’s active Practice charter is a pledge which essentially practices all primary care networks, or clusters to those in the devolved nations, can sign up by showing evidence that they’ve completed five key criteria.

The other is about increasing physical activity for staff and patients. And the final bit is about partnering with a local physical activity provider. We have now over 500 active practices, which is fantastic. And over the last year we’ve seen the biggest growth in that challenge this year since its launch, which is fantastic. So, what do we want to achieve with it?

Well, obviously we want to start practices on that journey of embedding physical activity into the work that they do. We also want to use that as a, as a sign, the fact that primary care, care about physical activity, that they want to get behind this movement and they want to encourage for more change, to allow them to do this better and more.

So the more practices that we can get signing up to this, the more we can show that, look, primary care engaged. They want to get involved. Let’s support them. Let’s make this job easier.

Tara: It’s fantastic initiative and thanks for sharing that so concisely. So mean that I mean that’s just one practical step for healthcare professionals, isn’t it, that other any others that you could that you could share?

Because if I were listening today, I would be thinking, okay, I need to get involved here. This isn’t rocket science particularly. The benefits are obvious, and we’ve heard some fantastic anecdotes and. Okay, so listen, both of you all kind of get involved.

Hussain: Well, it depends where you are. Your first step could be if you want to just increase your own physical activity levels, that’s you getting involved in my opinion, we know that that will help you become more confident in doing the same. When you’re engaging your colleagues and patients, you may want to explore some of the resources we’ve touched on before. Consider training and upskilling yourself in the area. I’d highly recommend whether you’re in secondary or primary care, to contact your active partnership. So active partnerships if you’re based in England, 43 different regions where they support their local area to increase physical activity and help them overcome a number of areas and inequalities that may be existing.  In Wales they are developing their own active partnerships as well, and in Scotland, a number of the regions have within the councils departments which are around trying to increase that. So definitely engage with your community, engage with your physical activity sector and see what can be done. Start off small, then over time, naturally things will come about where you can access them.

But if you don’t know each other, if you don’t communicate with each other, nothing will ever happen. And my final tip is have conversations about it in your teams. Discuss it often. There will be a few people that are really passionate about it. Maybe they can lead this. They may not be senior in terms of their leadership level, but their passion will help drive this.

And you can give this as a side project, a quality improvement task. We always have to show evidence of developing and this could be the personal development plan. So yeah, do sometimes look outside of the box as to who can support in terms of the role or position and yet upskill yourself.

Tara: Any tips from you Hayley. Any resources or tools that the listeners could, could access to engage with this?

Hayley: Yeah, I think the key is what I in was saying. No, it’s about conversation isn’t it. And connecting to this agenda personally. And this is right where you started. And I think I would also reflect I recognise we haven’t touched on this, but people working in the health system and in very, very different contexts and roles, you know, you might be in a row where you want to be all day.

You might be working shifts, you might be in an office-based job, desk job. And I think it’s also got to be adaptable. We’ve got to, you know, understand people’s context and conditions and then and then support people in that way. So I think starting conversations, you know, at home in your community, in your, in your job is the is the key.

And don’t yeah. Don’t wait for it to kind of happen top down I think it’s a movement for movement. Everyone’s got a role in the contribution to play, and it can be as simple as starting a different kind of conversation with a colleague. As the saying was talking earlier about the way that the primary care system is connected with the health system and is connected with Park Run and the swimming pool and all the rest, that’s where the real change happens.

And imagine, like if we can create the conditions for that in every neighbourhood across, you know, across the UK

Tara: Thanks Hayley, and you know to his signs point about active partnerships and you’re a great example in Greater Manchester. You know we work for sport and physical activity works with health in in in so many places.

So, our work for example putting gym in in Hussein’s neck of the woods, you know, we’ve convened local skills boards and, and around every single board there is a there is an IOC team will be there is a local authority there in primary care is represented. Well. There’s an active partnership. There are employers and employees of sport, and there are leisure operators, fitness, sports clubs, you name it.

They’re all around the table and education is around the table as well. And they’re all talking about local priorities and saying I in my area slips, trips and falls in my area, diabetes in my area, you know, tackling obesity and the efficiency of it in local outcomes through collaboration and partnerships is extraordinary. Right? So, if there’s a listener here who’s going up there and you oversaw the budget, again, look no further.

Honestly, that integrating physical activity into health will save you an absolute fortune. But I think, you know, if there’s a takeaway from today for you as a professional, just moving more is so good with your own physical and mental health. You’re busy people. You’re under some pressure. And you’re going to stay busy and under pressure if we can’t prevent people from overwhelming you.

So this is such an obvious conversation to be having. So, listen, Hussain Hayley, thank you so much for such an insightful, energetic, innovative session today. I hope the listeners took loads away. And for those of you who haven’t heard, the other said, this is one of a series of podcasts available to support you. The NHS workforce.

So yes, it’s all around the Four Ways Forward I talked about. Thank you for listening. Do during the next podcast and we’ll see you again soon. Thank you for listening to the Four Ways Forward podcast produced by NHS horizons for NHS England.

Podcast 4

Physical activity to prepare and recover from illness: A conversation with Zoe Merchant, AHP Clinical Lead for the rehab for Cancer Programme and Jack Murphy, Prehab4Cancer Programme Manager for GM Active

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. 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.”

Zoe Merchant, AHP Clinical Lead for the rehab for Cancer Programme: Hi everyone, I’m Zoe Merchant. I am the AHP Clinical Lead for the rehab for cancer programme in Greater Manchester. I’m an occupational therapist by background. I also manage the lung cancer screening program in Greater Manchester. And I’m joined by Jack over to Jack.

Jack Murphy, Prehab4Cancer Programme Manager for GM Active: Hi, Zoe. It’s always lovely to see you. Yeah. Hi, everybody. I’m Jack. I’m a cancer programme manager, so I’m responsible for the day-to-day delivery of the prehab cancer service across Greater Manchester.

Zoe: Great, Jack. Right. So you all listening to the final episode in a series from NHS England and NHS horizons exploring the benefits of physical activity and exercise and the Four Ways Forward initiative. This episode is a little different to the rest because we get to specifically talk about exercise and cancer.

So we’ll do a deep dive into what’s a very serious subject. I’m really keen to ask Jack about how he got into exercise. So, Jack, tell us how you got into the role that you’re in, if you recall. So the first time that we met.

Jack: I think we discussed this very topic when we first met. And I did come to tears at the time. So hopefully that won’t happen again. Exercise has always been very important to me. Sadly, I lost my dad at a very young age to cancer, and he had a very rare form of spindle cell sarcoma. And he was very fit and active himself.

I suppose I used exercise as a bit of an anchor for my mental health. It was something positive to focus on during that time. So, yeah, I suppose it was for my own wellbeing. But out of that, it’s evolved into a deep passion because of my understanding of the benefits of exercise.

And that’s obviously driven by a personal experience from losing a loved one family member to cancer and the benefits that exercise can have in relation to a cancer diagnosis. So as far as I’m the perfect position, in relation to my career and to support people with exercise in relation to a cancer diagnosis. And what about yourself?

Zoe: So actually, as it happens, I’m about to run the Amsterdam Marathon on Sunday. So I’m very focused on exercise right now. But for me, I’m an occupational therapist by background. The, the main tenant to occupational therapy is about using occupation, meaningful activity, for improvement and quality of life and about it’s about, you know, it’s therapy essentially.

I’ve always been, someone who really believes in that and been involved in lots of different things. But, when I got into doing rehab around the same time I’d had I had young children, and I started to get into running, and I realised for me, you know, this was a really good way in terms of how I manage my mental health if I’m running, what I find is that I just feel a lot more stable.

I have less anxiety, you know, my mood is positive. It helps for me that I run with a, like, a community running club. Shot out to Gatley Runners! So, you know, our every day, every morning, 6:30 a.m, I meet somebody at a local spot, and we go for a run together. And so for me, exercise has been a massive boost in terms of mental health and in terms of enabling me to do everything I do in my day, including work and managing family life, etc.

And it’s been hugely important to me.

Jack: So yes, it’s having that accountability to another person or an organisation or a group of service can really help with motivation in relation to exercise and physical activity.

And just being able to show up for another person can be really, powerful and I just want to touch on physical activity in exercise, because those two words are used interchangeably quite often. And exercise is a very scary word to some people. I’ve personally supported well over a thousand people now that have turned up for an assessment at our service, and majority of people are put off by the idea of exercise, because it’s often portrayed to us in a way in which we need to sweat profusely and, high intensity and what have you just touched on the difference between that physical activity and exercise, which one is it?

Zoe: So I actually feel quite strongly about this. I know it might seem like it’s semantics, but I think the difficulty is, that if you say to somebody that you can just do a little bit of physical activity, I appreciate that that feels potentially sometimes, an easier concept to somebody and a bit less scary than the word exercise.

But when we’re talking about rehabilitation and cancer, this isn’t just a nice thing to do. You know, go for a walk and that’ll really help. There’s actually a lot of scientific reasons as to why we’re asking people to do pre-rehabilitation. Well, I mean, speaking of marathons, what we often say is, if you’re going into a marathon, you won’t do that without doing some training beforehand.

A lot of the cancer treatments that we offer patients, whether that’s having a surgery, you know, an operation, whether it’s having chemotherapy, radiotherapy, immunotherapy, we’re asking a lot of the patient when we do these treatments, we’re asking a lot of their bodies. And so sadly to prepare physically and mentally and nutritionally and psychologically for that, just doing a little bit of physical activity isn’t necessarily going to bring about the changes that doing exercise would do.

The way I see it is physical activity may be walking down to the shops every day, or it might be just going up and down the stairs a couple of times a day. That’s, physical activity. For some people that’s a lot. And that could feel, enough to embrace what’s happening with their bodies.

But actually, for most people going through, a cancer diagnosis and being offered surgery and other things in order to gain the most benefit, we really need them to be engaging in exercise. So we really need to have a proper assessment, and we need to be understanding what it is that they should be doing. And you can speak about this much better than I can.

Jack: You said exactly how and how I would frame it. So, and I often have this conversation with patients about the understanding of the difference between physical activity and exercise. Yeah, going to the shops for a walk is okay. Please don’t stop doing that. Well. So physical activities, movement or exercise is structured movement with an intent and a purpose.

So when you’re given a cancer diagnosis, it’s really important that we introduce a little bit of a challenge in the body so that we can help to build additional fitness. So if it’s cardiorespiratory fitness for example we need to place some structure around building aerobic capacity to help improve the physical function of the body.

Zoe: And I think what’s interesting is that depending on which health care professionals you speak to, you’ll get a very different view about how people feel about this topic.

Some people think it’s not fair for us to use the word exercise and that we should be sticking to physical activity because it’s more palatable to people. And I know, and it’s hard, you know, especially for the health care professionals or other people involved who work with people who’ve had a cancer diagnosis. There’s lots of patients we can think of or people we can think of, who the thought of asking them to do exercise feels insurmountable or like not something that you should be doing. But actually, I think we need to be clear going forwards that really, you should think about exercise the same way you think about giving somebody a medication. So the same way you think about giving chemotherapy. And yes, it is a scary word. And for some people it is going to be.

Well I’m not sure I can do that. I don’t I don’t want to do that. But it’s all of our job to be breaking that down and to be supporting people and to be helping them to understand that we’re not going to ask them to go out or run a marathon when they’ve never even put some running trainers on.

That is not what this is about. Well, we’re going to be doing is we’re going to be working with every individual person. I’m going to be understanding what they’re capable of doing, and we’re going to just be asking them to push themselves enough that it’s something that they can do, but also they’re going to get the absolute best benefits when they go through their cancer treatment and they go through the pathways that they’re going through, rather than focusing too much on the word physical activity versus exercise.

I think it’s about how you’re working with individuals, and patient-centred care.

Jack: That’s exactly it Zoe, it’s all about patient-centred care, understanding the psychological impacts that a cancer diagnosis can have on an individual. And then on top of that, you’re asking them to do exercise and the stereotypes that exist around exercise. It’s really scary. So physical activity can be a bit easier to digest. It can be a gentle nudge through the front door of exercise. And I suppose that’s really where our service and prehab for cancer and you and Professor John, were fundamental in the design and set up and implementation of the pre-op for cancer service. Can you tell us how that came about?

Zoe: So, people might be aware, but there’s another program that’s called Eros. And we’ve we referred to our imaginary professor Jamil. He’s a consultant anaesthetist. So he was very much involved in what was called the year programme originally.

And I think what he realised, certainly where we work in Greater Manchester, there’s lots of people out there where if you say to them before you have this surgery or before you have chemo, before you have, you know, radiotherapy, you need to be doing lots of exercise. They haven’t got the foggiest of where to start, not least if they’ve just been told they’ve got cancer.

You know, it’s one thing to ask somebody to do something in the best of times. If you then asking somebody when they’ve just had that devastating news and they’re on the floor to suddenly go and do something that they don’t have any confidence to do, you know, that’s not enough. And that’s not good enough. And so there was a kind of recognition that really we need to be, in a position where we’ve got that support embedded into the NHS and so, we decided in Greater Manchester that we would get this programme up and running, and prehabilitation, is not just about exercise. But it’s also it’s, it’s what’s called multimodal. Partly it’s about how you prepare people physically. Part of it’s about nutritionally what people are eating, what’s going on from nutrition perspective. And then the final bit is the psychological bit. And so essentially, Professor John Moore was able to secure some money for something across Greater Manchester, with all the different leisure organisations and all come under the banner of Greater Manchester Active, which is what we’ve got on our shirts.

And it was about how can we, take patients who were being diagnosed with cancer in the run up to them having their, surgery or other treatments? How can we deliver a programme for them? That means that they’re going to be as physically and mentally and nutritionally prepared as they can possibly be to get the best outcomes when they go through that treatment. And there was already some evidence available about this in the literature, some research done, some indication, but it was very much in its infancy. What we did was over the first couple of years, put a team of people together who were all experience and exercise qualifications and exercise, used to work with people with lots of different health conditions.

And then we got this programme up and running, all the hospitals in Greater Manchester, which were ten different hospitals, could all refer in. And we picked out some specific cancers that we knew this was going to work best for. So people with lung cancer, people of colorectal cancer, people with upper gastrointestinal, cancer, and that was in 2019, we started, and we’ve been going ever since.

And I suppose the final word I will say is that when you tell people about this, it seems very common sense. And I think we’ve had so much support from all sorts of different healthcare professionals – surgeons, oncologists, nurses, allied health professionals, physios, dieticians. We’ve had a lot of academic support in how we do this and how we designed it.

Because this is something that you can absolutely get on board with. And I mean, I think it’d be great to hear from you about what it means on the ground and just the what the impact is for patients who go through the programme.

Jack: Yeah, I think that’s the importance of the people for cancer service and the impact it has on the individuals that we support day to day is massive.

I had the privilege of supporting over a thousand personally supporting over a thousand patients through the service. Now we’ve had over 10,000 referrals to date, and to a 75% of patients that get referred into the service. Do take us up at that point, because I suppose a cancer diagnosis and going back to what we discussed earlier, it can be a real teachable moment.

It can be that moment in which a person can take control back and do something positive, really empower them to take that control back from the cancer diagnosis. I met a gentleman in Salford on Wednesday, and within three weeks it increased his six-minute walk to us by 98m. It increased his sit to stand test, score by four for repetitions.

So are just signs that within a three-week period you can get fitter, which can reduce your risk of post-operative complications, get home after surgery much quicker. And but for the patients themselves, they can get back to the families that their lives much earlier and can really help to enhance their recovery.

Zoe: We all do it, but let’s do a bit of jargon busting. So what’s a six when it will test that?

Jack: A good question, yeah, I’ve just kind of fluffed over that as if everyone knew a six minute. Well, it says so six minute walks us because we don’t have when we’re working in the community, in the public leisure facilities, we don’t have the privilege of using sophisticated equipment. So, two cones ten meters apart walk as much distance as you can within the six minutes.

And it can be a really good indication of, a person’s fitness. So of course, low fitness scores would indicate that that person is potentially higher risk for surgery. So what we’ve got to do is improve six minute what’s our scores as much as possible for that person demonstrating that we’re getting them fitter. And as a result of that, reducing, any post-operative complications and supporting early recovery.

Zoe: That’s the cardiovascular aspect, what’s the other bit that’s really important? So the set to stand.

Jack: Yeah the sets to stand. So yeah the increase in four repetitions I also dropped in and some do it from a seated position requires strength in our muscles. And some of the people that come through the service can’t do that. They struggle to stand unaided after working with them for a few weeks.

That that ability returns because it’s a loss of strength. And as we age, unfortunately, we do get that gradual reduction in the size and strength. But it pleased to say that age isn’t the determining factor in that it’s often physical inactivity. So we know that if a person has any prolonged physical inactivity, then you will get a deconditioning effect on the body so they will get weakened, less fit as a result of that and just bring in the psychological impact to the cancer diagnosis back in, rest is not best. And it used to be, it used to be prescribed to people that are impacted by cancer and as well family, friends. We think we’re doing well for the person that we support with a morning tea and with them wrapped up on the sofa.

That’s often the worst thing that we could do because we will get that deconditioned effects. If you couple that with impactful cancer treatment, injected with chemicals and zapped with radiation, it can only accelerate that deconditioning effect. So it’s really important that we get moving. We bring in some movement that suits the patient.

Zoe: One of the things I was going to add in with all of that is that when we’re thinking about the rationale for rehabilitation and the science behind it, something that’s really important for people going into, any kind of cancer treatment is about muscle.

You know how strong someone is. This is a word I’m going to use called sarcopenia. So some people are know what that means. Some people won’t. But what sarcopenia means is muscle wastage. And obviously this is something that’s quite common as people get older. It is common with certain health conditions as well. If it’s left untreated, then actually what it can turn into is what’s called Cachexia. That’s where your systems are really breaking down. And interestingly, you know, when it comes to sarcopenia, when it comes to doing strength training, it’s not just for people who’ve got a cancer diagnosis. The chief medical officers guideline is about, exercise. It states in there that so anyone over the age of 65, regardless of whether you’re healthy or whether you’ve got any kind of health condition, you should be doing at least two times a week sessions of strength training.

I mean, I’m 43 but even I do strength training every week because I know my muscles are slightly going down, the pain as I become perimenopausal and other things. But it’s important when the cancer pathways for people who’ve been diagnosed with cancer, because actually what the research tells us is that if you’ve got sarcopenia, so if your muscles are wasting and you go into surgery, you’re not going to do as well as somebody who doesn’t.

And so there’s really clear evidence that shows that people going through surgery. The outcomes from this area was that more likely to have perioperative complications that what that means? Again, still a bit of a jargon busting is that after the surgery, they’ll have complications. That means that they’re in hospital for longer and they’re not doing as well.

And actually half the time with cancer surgery, it’s not necessarily the cancer. That is the thing that we’re really focused on. Just putting somebody through surgery is it’s a big deal. You know, a lot of surgeons or a lot of anaesthetists. Professor John Moore, they’ll tell you is that actually if somebody goes for a major operation, it’s probably going to be the biggest onslaught their body has in their entire life.

So a lot of the work we’re doing, it’s not just aimed at people have cancer, it’s aimed at anyone going for major operations. And it is about understanding that you’re more likely to be alive one year down the road, or you’re more likely to not have those kinds of complications that can make people unwell, if you’re going into that procedure as fit and as strong as possible.

Jack: I think what I hear you saying, there’s always that we could actually be doing more harm by not prescribing exercise to somebody that’s been impacted by cancer or that is a in surgery.

So I, I feel like I still feel like banging my head off the wall sometimes. The exercise and physical activity that we’re still having this conversation that isn’t just standard care because it should be. I mean, the evidence is massively overwhelming. Now, just as you mentioned, the guidelines 150 minutes of moderate intensity exercise a week, including the two sessions of strength training to support activities of daily living.

So if you have a surgery and you’re not strong to begin with, it’s going to be a lot more difficult to get up and out of bed after the operation. So I suppose you pulled in a plus before or enhanced recovery after surgery, and it’s building it all together. It’s bringing all together that the very first moment that you receive that cancer diagnosis, your recovery from that starts from that point.

If you want to curative in some pathway, of course. Exercise can improve, so reduce the incidence, progression and metastases as cancer as well. And it can also improve the efficacy of treatment. So if you are undergoing chemotherapy treatment radiotherapy exercise has been proven to improve the efficacy of that due to the machines that are released, your own muscle strength working and high intensity interval training as well.

Zoe: We’re aware of how people might feel being asked to do exercise. So what did the conversation’s another controversial conversation that comes up with healthcare professionals is it fair to ask a cancer patient to do this when they’ve just been told they’ve got cancer? So often we talk about, the burden that we might put on somebody who’s just had that diagnosis.

And it’s not just the person themself; it’s everyone. He’s around them, it’s their family members. It’s, you know, it’s their parents, it’s their children. It’s people that care for them. And I suppose one of the things I wanted to highlight was that when we’ve designed, we have the cancer programme, but across the boards, it’s not just us because there’s other rehabilitation services in the UK and, and elsewhere in the world.

We’ve had lots of people who’ve been diagnosed cancer involved from the start. So actually, helping us to design it helping is to, think, what’s the right way of going about this? You know, we did a brilliant focus group when we first started. We said to patients, what do you think about this? Like, is this something that’s palatable or not?

And I think what I took away from that is that people really did say that it’s absolutely the right thing to be doing. They want to be able to take control. You know, people told us that sometimes when you get told you got cancer, you feel like you’re on a conveyor belt. You go into hospital, you have surgery, you come home, you’re at home, you kind of just got to get on with your life again.

And that you kind of being done to all the time. You’re having tests and you’re having surgery done, you’re having chemotherapy done, and that you don’t have any control over what’s going on. And so, for me, you know, whenever I think about how amazing, this, this programme is, that’s often what comes up. And actually, I want to tell you this, Jack. So I was at a conference in Wales on Wednesday, which was all about rehabilitation and in Wales, and there was a woman there, and she told me that her best friend had come to prehab for cancer during Covid.

And she told me, and she had tears in her eyes, which makes me feel emotional. But she told me that it was one of the best things that happened to that person during the time that she had her cancer.

This lady was doing sit to stands in her very final moment. She was a lovely person to work with and very inspirational. It’s really heartwarming to hear the stories and the feedback that we get from many people that we’ve supported through the service. Again, you can’t even put into words to the impacts that we have. And yeah, many, many people that I feel inspired by that we’ve worked with every, every single day.

Yeah. I think for me it’s like we can talk about the numbers. And obviously for us, we’re really proud that we’ve had 10,000 people referred, that we’ve had this many people attend the service. But I think all of us involved, you know, there’s individual stories to be, to be pulled aside in a meeting and to be told, you know, this meant so much to this person and her family and her friends that she had this and that she was doing this, and it wasn’t us doing it to her. This was something that she was doing. She was taking control of, you know, sadly, that patient ultimately, she didn’t survive the cancer. And I think we, you know, we need to be clear sometimes that sadly, regardless of all the different treatments available, regardless of all the different interventions we might do, it’s not always a positive outcome for people.

But what’s amazing to hear that despite that, the fact that somebody come along to the programme and engaged in the program and been able to go through what was awful and none of us could ever wish it on anyone and be positive about it. You know that to me, it’s those individual patient stories that make me so enthusiastic about what we’re doing.

00:25:21:24 – 00:25:51:07

Unknown

Yeah. I couldn’t agree more of it. It’s it’s very much that the people that we support are really, really powerful stuff. And we don’t always experience a positive outcome. We’re working with people that have been given a cancer diagnosis. And but it’s also the quality of that person’s life. So staying strong and fit for as long as possible so that they can still do the things that they want to do to enjoy however long it is that they may have left.

And if it’s the same person that, I think that you speaking about. So this person was able to get back to, to Ireland to see her family and, and were still able to be, to be fit and strong, to go for walks and hikes that she liked to do.

Jack: So I do think we should talk about what you actually do with people because again, I think right now someone’s going to think, oh, this all sounds great, but do they, you know, it’s somebody in the gym like, you know, having to do like, all sorts of crazy things on a bike and, you know, like that’s their, their the stereotypes of exercise that

you mentioned, there’s oh, burpees and sweating profusely. I could not do anything. I’m just sick. And I just have not figured out how to do a burpee. Full disclosure.

Zoe:

 Anyway, so if Mrs. Jones came along to Jack, you know, let’s take, I don’t know, somebody in her mid 60s has an exercise for many years. Sadly, he’s just been given a diagnosis of cancer.

00:26:45:23 – 00:27:07:02

Unknown

Has agreed to come along to the gym. The local leisure center is feeling pretty anxious about what she’s going to get asked to do. Turned up in a kind of jogging bottoms and some trainers. What kind of things would you be asking Mrs. Jones today?

Jack: That takes a lot of courage. What you just explained. There’s a way for that person to do that, to turn up at the leisure centers, in the jogging bottoms are ready to engage in the service.

Yeah. Our responsibility is that person, obviously, to help support them, to get as fit as possible. So exercise of course, is our main responsibility, our priority. But you mentioned before it’s multimodal. So we carry out an assessment which is a fancy way of saying get to know the person, help to understand what they need from us as a support us as a service.

And I suppose as a community, as with the prehab cancer service. We bring people together in group, group exercise group sessions, whether that’s in the gym or away from the gym, in a studio, or it gives people that opportunity to share lived experience. Believe it or not, that’s not often an experience that they get just to speak to somebody else that’s been diagnosed with cancer and to share that experience.

And that’s where you get all the psychosocial benefits of group-based exercise as well, which can help to relieve anxiety, depression. So you’re getting all the mental wellbeing benefits of exercise as well. And but I suppose we deliver exercise to people. So that’s what we do. So it might be cycling, walking but it would be very specifically tailored to that individual.

I suppose a standardised way approach to exercise is through high-intensity interval training.

Zoe: So otherwise known as HIT Yeah.

Jack: Yeah. We manage the volumes and progressions to suit that a patient. So a lady that I was working with a few months, six months ago, 88 years of age, she came into the gym and the assessment, it got her on the exercise bike.

And yes, we were doing high intensity interval training with this, with this person. But of course, it would say to her ability levels, she had colorectal surgery and she made a fantastic recovery. She’s now back swimming, three times a week. She comes into the gym once or twice a week during our supervised gym sessions, during our recovery.

So yeah, it might almost scare people to hear that an 88-year-old, has been on an exercise bike in the gym, and she’s doing high intensity interval training. But the positive benefits that person can have are massive.

Zoe: So, take that person you just described. So obviously that’s the cardiovascular that you’ll have done, but what about the strength stuff. So what would you you’ve got her to do in terms of the strength exercises she would have had to have done?

Jack: Yeah. So we’re looking at some functional movements to help build strength in the major muscle groups. So again, you’re looking at you set the standard.

So you might do a weighted set to some to increase the amount of force that the muscles have to produce to increase strength. So yes, exercises that can support activities of daily living. Well, again, specific to that person. So if there’s any musculoskeletal conditions and any pain for example, any hip pain, then we might want to tailor the exercise selection to suit.

And when you do set foot in the gym, it looks like a room full of instruments of torture. But once you get on and you get using the equipment, you can you soon see that the very easy and comfortable to use. So it’s kind of breaking down those barriers to access and using the, using the facilities.

Zoe: Another aim that we have with what we’re doing is about lifelong behaviour change. So it’s about people continuing to do exercise. Yes we did. We didn’t want people to have to come to a gym in a hospital. What is like one bike. And again, it’s in this horrible place which they’re associating with the fact that they’ve been told that they’ve got cancer.

Instead, we wanted it to be that near where they live. They would wander along to their leisure center. They’d see their neighbour in there, they might see somebody that they know, you know, it’s an environment that is not to do with cancer. It’s not to do with hospitals. It’s a very normal environment. And to anyone else in the gym that does somebody else in the gym doing some exercise, which again, I know can be scary.

But actually, again, it’s, you know, 2 or 3 times a week, free gym membership, people coming along, able to access whatever else is going on in the leisure centre. And I think that in itself is really important. Because this is about how we, make people feel that, really, it’s, again, something really positive that they’re, that they’re engaging in, they’re doing.

And like, we know, not everyone, is ready for coming back afterwards, but actually the majority of people want to continue doing exercise, talk to us about kind of the exercise and a physical activity. We might someone might do afterwards when they’re kind of in that recovery phase, after they’ve had the treatment.

Jack: Yeah. A really important point. So obviously the prehabilitation phase, that small window of time that we’ve got to work with a person, to support a person to get as fit and as strong as possible for their surgery or treatment. 3 to 4 weeks typically. So it does need to be a bit more intense for the recovery and the rehab element.

That can be a little bit more relaxed, it can be more person centered, and the rehab is more tailored to, what they enjoy doing, what their likes and interests are. Well, I’m, I always think is great is that somebody might go on to do like line dancing or someone might go on to do like Zumba or like, you know, for example.

And so a lot of what we’re trying to do is once people have, you know, leaving the service and leaving the program, it’s like, what do you want to be doing? For me, it’s always trying to let people know that we deliberately do a very specific exercise programme before, as part of the prehab portion, and actually during as well.

Zoe: So the definition of prehabilitation has just been updated recently. And if you’re having, chemotherapy and radiotherapy, you would be doing your rehabilitation during at the same time.

Jack: Yeah. That’s a really important stage in the pathway for people as well as all the support that we offer into them, because we know how impactful chemotherapy treatment is.

And the impact that that can have on the body. So we want to reduce any deconditioning effects on the body during that time. We fully encourage people to stay as active as possible and still come to attend leisure centres so we can support them during chemotherapy treatment. Yeah, of course we would adapt our exercise prescriptions, support that that patient based on their based on their needs on any given, any given day.

But yeah, we fully encourage people to stay active during chemotherapy treatment and all of the evidence supports. And so,  what’s the call to action? How do we get the message across to other health care professionals, to integrate physical activity and exercise as standard into care pathways?

Zoe: So this a there’s a few things that I’d want to say in response to that. So, I didn’t mention it before, but I’m part of the national group, that have written the NI guidelines. So, people might already have heard of the Macmillan Rehab guidance that was released in 2019, of which there’s a lovely picture of Jack in that document.

If anyone wants to go and find it, he looks a bit younger. Okay. Looking very different. But that was from 2019 and we’ve just gone through a huge process, led by Macmillan and the Royal College of Anesthetists, the British Dietetic Association, the World Health Organisation, and we’ve done a two year systematic review of looking at all the evidence that exists for rehabilitation and an updated the guidelines, which, if anyone wants to find it, look on the Macmillan website, which is where it will be hosted.

 So for starters, I would really recommend that healthcare professionals go and find that document because, what we’ve done is we’ve taken all the research and all the evidence, we’ve, you know, agreed guidelines of how you deliver rehabilitation, what you need to be thinking about, what is the best evidence around it, which, who, who in the workforce should be involved.

You know, exercise professionals, allied health professionals, psychologists, cancer nurse specialists, all the different people who are involved. So I would really recommend people go and have a look at that document. The bit of it I was involved in most was the health economics. So often, you know, the science of rehabilitation I think is quite easy to understand.

And I think hopefully we’ve covered that off. But what we know, and certainly locally in terms of the evaluation we’ve done of private cancer, we’ve shown that actually, if you compare people who do prehab to people who’ve had the same kind of cancer, same kind of treatment, the same kind of people and haven’t done rehab, it costs more money.

And in in the healthcare delivery to do that. So actually we’ve shown that, it’s roughly three times more expensive for the patients who’ve not done prehab to those that have sort of essentially pre rehab is delivering a free times return on investment is fancy terminology. So we did an evaluation when you know two three years into the service.

And then we’ve done it again just recently. We’re showing that for some patients absolutely they get out of hospital quicker. They don’t have as many days in hospital which is obviously costly. They have less readmissions to hospital, less admissions into A&E. The really amazing thing that we’ve been able to see is that actually people who do prehab compared to people that don’t, if you compare whether people are alive at one year or five years, which we’ve been able to date because we’ve been running the service for that long, there’s a better survival for people who do prehab.

And if you compare this to drugs, you know, it would be the most prescribed joke in the world to be able to show that we can actually have that benefit. But we’ve also looked at other evaluations, that of other services elsewhere that have been conducted independently. So, for example, in Sheffield, Leeds does the Active Together service. Across the country there’s lots of different rehab services. And actually what’s really reassuring is they’re all finding this. There’s a health economic benefit from doing prehabilitation. And actually there again is this improvement in survival. To me it’s a no brainer isn’t it.

Jack:

it’s astonishing isn’t it. The findings that we’ve been able to demonstrate and yeah, literally saving lives through the delivery of rehabilitation and recovery programs. And it’s great that so many other fantastic rehabilitation services are popping up nationally now as well. It’s really that why do you get out of bed in the morning.

Well doing it to save people’s lives that are impacted by cancer is massive. Yeah. And I think as again, just a bit of feedback that we get from patients’ day to day so that that that voice, the health care professional is really trusted to patients. Patients trust that nurses, their doctors, their consultants. So be an advocate for exercise and physical activity.

Really encourage and get advocate for patients to engage with exercise and physical activity. Because of all the reasons that we’ve discussed today and the benefits that it can have to that person, I’m conscious that obviously, you know, we’re banging on about this brilliant service we have in Greater Manchester. And so you know, if we had to kind of tell people listening from other parts of the country, about how to think about this, how to do more, you know, we’ve got a website, we’re WW, DWP rehab 4 cancer.co.uk

If you search Macmillan Rehabilitation, there’s lots of information; NHS England. We’ve got psi UK, another charity. We’ve been involved in creating some videos. We’ve got lots of videos available on YouTube. Again, if you search for prehab for cancer on YouTube.

Zoe:

So we understand that, not everyone’s in a lucky position that they’ve got a rehab service.

They can refer a patient into. So the lovely Jack, you can see him doing videos of various different levels of strength and cardiovascular exercise, which people like my mother in law, he lives down in Dorset. She does tai chi with Rob, which is one of the prehab for cancer videos every. I think she does every other day. She constantly tells me when which about going to make another tai chi video.

I mean thinking about it. There’s also the, you know, movement is medicine. Website, which again, that’s got all the different health care conditions. So for any health care professional who’s thinking, right, well, how do I speak to my patients about, getting them to do some exercise of physical activity? It’s got really helpful instructions and videos that are one minutes, five minutes and ten minutes that can talk to you about if you’ve got one minute or you’ve got five minutes with a patient and you want to talk to them about exercise, this is some advice of what you can do.

You know, it’s great. We have got loads of different resources available to us haven’t we. But equally, I think our goal is to make sure that there’s more comprehensive pre-publication services available across the country. And actually, people will be pleased to hear that from a cancer perspective, in the NHS cancer plan and in the 10- year plan that’s come out recently, you know, exercise is part of that.

You know, prehabilitation is certainly part of the cancer plan. This is starting to be something that’s not just a nice thing to do that some people are doing is starting to be absolutely embedded across all the strategy and all the policies and the planning guidance that health care professionals and managers have when it comes to thinking about what they should be doing.

Well, look, thank you so much for joining me, Jack. You know, I’m I like the work you do and what the team does have so much pride in being able to work with you all. And thank you to everybody who’s listened. Hopefully we’ve inspired you to maybe just go and do some exercise yourself. Perhaps actually think about how you’re going to encourage the people that you work your patients.

You know, if you’re a health care professional or if you’re a NHS manager, how you’re going to think about making sure that exercise is part of the work that you’re doing. Remember, there’s a total of four podcast episodes in this series exploring the full ways forward. Please data and to all the exercise if you haven’t already. And I think that’s everything, for now.

So thank you very much for listening. Thanks, everyone.

Jack:

Thanks, bye.

 Thank you for listening to the Four Ways Forward podcast produced by NHS horizons for NHS England. You can listen to all episodes in the series by visiting England dot NHS stuck and searching the words for ways forward.