Aim Sport and exercise medicine (SEM) aims to manage sporting injuries and promote physical activity. This study explores general practitioners’ (GPs) awareness, understanding and utilisation of their local SEM services.
Design A questionnaire survey, including patient case scenarios, was administered between February and May 2011.
Participants and setting 693 GPs working in Cardiff and Vale, Leicester and Tower Hamlets were invited to participate.
Results 244 GPs responded to the questionnaire (35.2% response rate). Less than half (46%; 112/244) were aware of their nearest SEM service and only 38% (92/244) had a clear understanding on referral indications. The majority (82%; 199/244) felt confident advising less active patients about exercise. There were divergent management opinions about the case scenarios of patients who were SEM referral candidates. Overall, GPs were significantly more likely to refer younger patients and patients with sport-related problems rather than patients who would benefit from increasing their activity levels in order to prevent or manage chronic conditions (p<0.01). GPs with previous SEM training were significantly more likely to refer (p<0.01). The majority (62%; 151/244) had never referred patients to their local SEM clinics but of those who had 75% (70/93) rated the service as good.
Conclusions There is a lack of awareness and understanding among GPs on the role of SEM within the National Health Service which may be resulting in suboptimal utilisation especially for patients who could benefit from increasing their activity levels.
- EDUCATION & TRAINING (see Medical Education & Training)
- MEDICAL EDUCATION & TRAINING
- PRIMARY CARE
- SPORTS MEDICINE
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- EDUCATION & TRAINING (see Medical Education & Training)
- MEDICAL EDUCATION & TRAINING
- PRIMARY CARE
- SPORTS MEDICINE
Sport and exercise medicine (SEM) was recognised as a specialty in the UK in 2005.1 SEM specialists receive training to address medical conditions and injuries in those who are physically active and engage in sport and advise on the safe use of physical activity as a preventative and therapeutic tool.2
Given the increasing public recognition of the importance of physical activity and the rapidly expanding research base demonstrating its benefits, SEM could play a key public health role in promoting health through exercise, an3–6 especially important role given the rising prevalence of obesity and its associated chronic diseases. Increasing activity levels in combination with a healthy diet are recommended by the National Institute of Health and Care Excellence (NICE) as the main strategies to help people achieve and maintain a healthy weight7 and are advocated for the control of chronic conditions such as diabetes. However, the implementation of these strategies requires a systematic approach including policy, planning and workforce changes8 and careful consideration of how SEM’s role in promoting exercise can be fully used within the National Health Service (NHS). It is not clear whether such an approach has been adopted across the country.
As of April 2012, there were 54 SEM consultants working in the NHS and 48 doctors in training.9 Though increasing, these figures are still below the target of 180 NHS consultants which the faculty of SEM suggests are required to deliver a nationwide service.10 Specific SEM services and provision vary depending on location. Often, NHS SEM clinics are part of orthopaedic or rheumatology departments of acute trusts and are available on Choose and Book referral system.11 In a few areas, they are based within primary care. The variation in service provision can be partly explained by the fact that SEM bridges several different specialities, but it may also reflect ad hoc service development without coordinated planning and clear strategic direction.
General practitioners (GPs) are the first point of contact for most patients and the main referral source for primary and secondary care services. Although 60% of GPs in previous surveys felt that SEM should be a recognised speciality within the NHS, 64% believed that the NHS could not sustain it,12 with ambivalence on the best setting.13 Lack of education on the role of SEM was identified as the biggest barrier to speciality.13 The faculty of SEM have produced guidance10 suggesting a balance between treating sport injuries and chronic illnesses with exercise,14–17 but did not specify how SEM services should be implemented in practice nor how they can become incorporated within existing clinical musculoskeletal or chronic disease pathways thus limiting clarity for commissioners and referrers.
This study aimed to explore GPs’ attitudes to SEM in order to assess whether GPs’ knowledge and referral match the original Department of Health vision in a variety of localities with NHS SEM provision. The objectives included an assessment of GP awareness of the availability of local SEM services, their understanding of the indications for patient referral and application of such understanding to case scenarios describing patients potentially eligible for an SEM referral.
Participants were drawn from three geographically and demographically diverse areas (Leicester, Cardiff and Vale (CV) and Tower Hamlets (TH)) selected as they all had access to SEM provision via the Choose and Book referral system and directory of services.11 Leicester and TH have high numbers of ethnic minority groups compared with CV while TH (in East London) has high levels of deprivation. None of the areas had access to primary care-based SEM services. The closest SEM services were: within an orthopaedic department of an acute trust about 25 miles away for CV and in an acute trust musculoskeletal unit for Leicester and colocated with secondary care rheumatology in TH.
GP participants were identified from Primary Care Trust databases checked against NHS Choices websites. All GPs in each area were invited to participate and no exclusion criteria were applied.
The study was presented to the National Research and Ethics Committee. Formal permission was not required and questionnaire completion was taken to indicate consent. The questionnaire was anonymous.
A 15-item questionnaire designed to explore GPs’ knowledge of SEM services was piloted and amended prior to administration (see online supplementary appendix 1). The questionnaire assessed general practice and SEM experience in order to identify potential confounders. Questions covered awareness of local SEM clinics alongside understanding, utilisation and satisfaction with the local service. Six case scenarios of patients with sport and exercise-related problems were presented and participants were asked to make management choices (box 1). For each question, participants were invited to choose from a list of prespecified answers including ‘don’t know’ (multiple choice design) and they were also given the opportunity to add their own text and elaborate on their answers.
Case scenarios of patients with sports and exercise-related problems
Please tick what you think would be the most appropriate management for the following patients (provided you had access to all the services mentioned)? Please tick only one.
A 30-year-old, morbidly obese patient
A 65-year-old patient suffering from moderate osteoarthritis of both knees
A 25-year-old patient who plays sport regularly and has been experiencing some instability of the right knee who had some physiotherapy a year ago and it did not help
A 40-year-old male with type 2 diabetes, BMI of 31 and family history of cardiac failure
A 54-year-old patient has been suffering from lower back pain for the past 6 years. He complains that it ‘prevents him from exercising’
A 30-year-old male recreational runner who presents with anterior knee pain when he runs and has a normal examination. He had physiotherapy and it did not help his symptoms
BMI, Body Mass Index.
The questionnaires were sent by post to GPs in Leicester and CV while an online version was emailed to GPs in TH, East London, between February and May 2011. A reminder was sent 4 weeks later.
The total eligible population was 693 GPs. A sample size calculation was performed using the Dilman and Cochran formulae indicating ∼248 respondents were required to generate representative results using a CI of 95% and a 5% margin of error.18 ,19 Previous questionnaire surveys of GPs showed response rates between 32% and 50%.13 ,20 As GPs have multiple time pressures, we assumed a response rate of approximately 35% and sent the questionnaire to all 693 GPs.
The dataset was coded and analysed using SPSS V.19.0. Results were analysed to determine awareness, understanding and utilisation of local SEM services. Responses to the case scenarios were analysed to explore musculoskeletal pathway management decisions. Subsequent comparisons were made between the three GP groups and to account for years of experience and prior training in SEM. Statistical calculations were performed for non-parametric data with Kruskal–Wallis H test, χ2 test (α=0.05) and Fisher’s exact test.
A total of 244 responses were received out of a total of 693 GPs who were invited to participate (35.2% response rate) (table 1).
Participants’ level of experience
Most respondents (57%; 139/244) had been practising GPs for over 15 years with only 12% (29/244) for 10–15 years. There were significantly more respondents with more years of practice in CV compared with Leicester and TH (χ2=32.58, p<0.001) (table 1).
Just over 1 in 10 of the participants (11%; 26/244) reported that they had undertaken some previous training in SEM, the largest proportion (15.4%) being respondents from TH (figure 1). There was no statistically significant difference between the three areas (p=0.26).
Local SEM provision awareness
Less than half of the participants (46%; 112/244) were aware of their nearest SEM service. The highest percentage was in TH (73.1%), with the lowest in CV (27.8%). The difference in proportions between the three areas was significant (p<0.01) (figure 2).
Understanding and utilisation of local SEM services
The great majority of the respondents (82%; 199/244) reported that they felt confident in giving less active patients advice about exercise. No statistically significant differences were noted between the three areas.
Only 38% of respondents (92/244) had a clear understanding of what cases needed to be referred to an SEM clinic. CV had the highest percentage at 46.8%. There was no statistically significant difference between the three areas.
CV had a significantly higher number of respondents who had never referred patients to an SEM clinic (83%) than Leicester (41%) and TH (31%) (p<0.01).
Respondents with previous SEM training referred patients to SEM more often (65%; 17/26) than those without such experience (35%; 76/218) (p<0.01).
Most GPs who had referred patients to local SEM clinics (76%; 70/92) were satisfied with the service while 23% (21/92) reported an average rating.
One of the questions enquired on the types of patients the respondents would refer to primary and secondary care SEM clinics provided they had access to these (figure 3 and table 2). Overall, respondents reported that they were significantly more likely to refer young patients with musculoskeletal problems compared with patients of any age (p<0.01). They were also significantly more likely to refer patients who exercise regularly or elite athletes compared with patients with chronic conditions who were interested in taking up exercise (p<0.01).
Understanding of MSK pathways of care
For a series of patients, participants were asked to choose the most appropriate next management step, assuming accessibility to all mentioned services (table 3). For the majority of cases, there was a divergence of opinions on the best care pathway. Again, GPs typically chose SEM clinics for younger patients who exercised regularly rather than older patients with chronic conditions.
Our study investigated GPs’ awareness, understanding and utilisation of their local SEM services in three geographically and demographically diverse areas and showed that the full potential of the speciality is not being used, especially with regard to the public health role of SEM in promoting physical activity.
There was low GP awareness of local SEM services with significant differences between the three sampled areas. The highest awareness was in TH (73.1%) possibly due to distance in CV and the long history of service provision and academic activity in TH. However, even in TH one in four GPs (27%) was not aware of their local SEM clinic.
The majority of respondents felt that the most appropriate cases for an SEM referral were elite athletes and patients with musculoskeletal problems who exercise regularly. This is in accordance with a study12 which showed that 72.7% of GPs felt inadequately trained to practice SEM, and 76% would welcome more training. In contrast, most GPs (82%; 199/244) reported that they felt confident in giving less active patients advice about exercise and did not choose to refer patients with comorbidities to an SEM clinic. This can be partly explained by the availability of relevant guidance from NICE and the Department of Health.7 ,21 Alternatively, this finding may suggest that treatment of this subset of patients is not considered by GPs to be a function of the SEM speciality, or may reflect a lack of robust evidence on SEM services’ cost-effectiveness.
Only a third (38%) of respondents had a clear understanding of when to refer to an SEM clinic. For the majority of clinical cases, there was divergent opinion about management of patients with the common musculoskeletal conditions presented, highlighting the need for clarification of local clinical care pathways. Although most GPs reported that they would refer young individuals with sport-related injuries to SEM clinics, a considerable percentage (18%–28%) would consider a referral to orthopaedics equally appropriate. It seems that there is no consensus on a clearly defined patient group(s) for SEM services. The siting of SEM at a nexus of orthopaedics and rheumatology may add to the confusion as to the exact role of the speciality. The location of most SEM services within secondary care may be an additional barrier to utilisation of exercise promotion functions.
The fact that the majority (83%) of GPs in CV had never referred patients to SEM clinics may be due to the longer GP experience of respondents, their low level of awareness of local services and the fact that SEM services were located further away. The high percentage of GPs who had never referred patients in Leicester (41%) and TH (31%) likely reflects a lack of agreed referral pathways.
The study had several limitations. The survey took place in three diverse areas to increase the generalisability of our findings, but we cannot be certain that the results represent nationwide practice and opinions. In addition, there was a lower response rate in TH, where the questionnaire was administered online, which limits the degree to which our findings in this area are representative. The overall response rate was low, possibly reflecting GP time pressures and research priorities. Anonymity was guaranteed to all participants to allay any fears of exposure of limited knowledge on the subject. Respondents were a self-selected group who potentially had a special interest in the subject. This may mean that there may be an even lower rate of awareness, understanding and utilisation of SEM services in the group of non-respondents.
Despite these limitations, the study provides a platform for further research on this subject. Our findings highlight the fact that, despite recognition from policy makers that SEM could be valuable to the NHS, there remains a lack of understanding among GPs on the role of the speciality and underutilisation of local SEM services especially for patients with chronic conditions who could benefit from advice on how to increase their physical activity levels. There seems to be a need for education on the role of SEM in the NHS and clarification of the relevant referral pathways for patients. Further studies should investigate the optimum method for delivering this information both to GPs and other healthcare professionals and to identify and address referral barriers.
Most importantly, at a time of increasing financial pressures, further studies are needed to provide evidence on the potential cost-effectiveness of SEM services and optimise delivery efficiency. A coordinated effort is needed to tackle the pandemic of physical inactivity.8 Clinical Commissioning Groups in collaboration with Health and Wellbeing Boards and Public Health will have an important role to play in evaluating and re-designing SEM-related services. Relevant stakeholders and policy makers should be provided with information on the particular speciality role of SEM and its potential benefits for preventing and managing long-term conditions if this new specialty is to thrive in the UK.
General practitioners (GPs) seem to be largely unaware of their nearest sport and exercise medicine (SEM) service and its remit.
There is divergence in GP opinions about when a referral to an SEM clinic is indicated perhaps suggesting that clinical pathways need to be clarified.
The dual role of SEM is not being fully used as GPs seem unconvinced or unaware of the SEM role in promoting physical activity for the prevention or treatment of chronic diseases.
Current research questions
What is the optimum way of delivering SEM services in order to fully use SEM's role of managing sport and exercise-related injuries and promoting physical activity?
What is the cost-effectiveness of National Health Service SEM services?
What is the most effective method of delivering information to GPs regarding the role of SEM services in order to maximise understanding and support Clinical Commissioning Groups’ decision making?
Cullen M BM. Sports and exercise medicine in the United Kingdom comes of age. Br J Sports Med 2005;39:250–1.
Sport and exercise medicine a fresh approach. 2012. 9-2-2012.
Cullen M. Developing a new specialty—sport and exercise medicine in the UK. Open Access J Sports Med 2010;1:11–14.
British Association of Sports and Exercise Medicine. BASEM Education—The future. 2012. 9-2-2012.
We would like to thank all the GPs who responded to our questionnaire.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement
Contributors VTB co-initiated and supervised the project, designed data collection tools, implemented the survey in Tower Hamlets, monitored the data collection for the whole survey, wrote the statistical analysis plan, contributed to the analysis of the data, and revised the draft paper. She is guarantor. HK designed data collection tools, implemented the survey in all three locations, wrote the statistical analysis plan, analysed the data, drafted and revised the paper. POH co-initiated the project, designed data collection tools, contributed to the analysis of the data and revised the draft paper. DM supervised the data collection and analysis, managed the budget and revised the draft paper. NM supervised the data collection and analysis and revised the draft paper. PW and JF revised the draft paper.
Competing interests None.
Ethics approval East London Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement We have a summary of all the survey responses which is available to other researchers from the corresponding author.