PHYSICAL ACTIVITY REVIEW Care Pathway/Service Commissioner Lead Provider Lead Board Approval & Comments Clinically Advised Physical Activity/ Rehabilitation Programmes. Helen Bailey, Locality Commissioning Manager Furness. Christine Moore, Locality Manager Furness. Approve development of a full specification for the Community Gym based on a sixteen week programme, and the implementation of the Let s Get Moving Pathway. 1. Overview & Current Position A review of the current provision of Clinically Advised Physical Activity programmes (Cardiac and Pulmonary Rehab and the service offered by the Community Gym) has been undertaken with a view to ensuring that the Locality is able to achieve the maximum benefit for Furness patients, from the resources currently invested in providing programmes with a physical activity component. This paper builds on the work started by Gary Malone in 2011, the discussion paper considered by the Board in August 2011 and Patient and Public Engagement undertaken by the Locality Public Engagement Lead and LINK in support of this piece of work. Current position The three elements of clinically advised physical activity provision funded by Furness Locality are all run by the Partnership Trust on behalf of the locality. Each is separately funded and operates independently. Cardiac Rehabilitation Phase III Rehab is undertaken by clinically qualified staff based at FGH and is run on a 6 week rolling programme. This is followed by the opportunity to attend Phase IV sessions for a further period, at a number of community venues (Singleton s in Barrow, the Methodist Centre on Walney and Ulverston Leisure Centre for those patients who live in or near Ulverston but are registered with a Furness GP). Cardiac Rehab is well attended with a relatively low drop out rate and positive feedback from both attendees and referrers however with the recent development of the Heart Failure Service, the current level of provision may prove to be insufficient. Pulmonary Rehabilitation In 2011 Furness Locality commissioned an increase in Pulmonary Rehab from 12 to 19 programmes a year. These sessions are lead by a qualified nurse and run for 6 weeks. Currently, all but one programme a year is run in Barrow with the other being held in Millom. All patients are offered the opportunity to consolidate their physical activity following the programme, with automatic referral to the Community Gym. Response to Pulmonary Rehab from patients and referrers is more equivocal with a sense that patients are less clear about the relevance of the programme to their recovery. Community Gym The Community Gym is run by a qualified instructor and support staff and is based at HOOPS gym on the Thorncliffe site of the Academy. Some Physiotherapy staff have recently co- located, and this is allowing greater use of the facility for individual physiotherapy led rehabilitation programmes. The gym currently has a range of clients, attending for a variety of reasons (see Appendix 1) 37% of clients are attending with no diagnosis specified, 26% have a mental illness, 11% are patients attending for general health improvement, the remaining 26%, with a range of specific conditions such as respiratory conditions, diabetes, or following a stroke. A new 16 week programme was introduced in April 2011 for all new attendees. Prior to that the majority of clients (74% of the total in January 2011) had been attending on an open ended programme. The Gym is highly valued by the people who attend and by those referrers who are aware and make use of the facility. The service is only available in Barrow however and its current location is not universally liked.
2. Evidence Base for Physical Activity interventions. The relevance and value of Physical Activity in preventing and managing a range of clinical conditions is well recognised and physical activity is specified as an intervention for a range of conditions in NICE guidelines. Cardiac and Pulmonary Rehab both have a strong evidence base but the Department of Health Statement on Exercise Referral (March 2007) states that high quality exercise referral schemes should only be commissioned where these:- 1. Address the medical management of conditions (eg type 2 diabetes, or osteoperosis) or 2. Provide approaches specific to preventing or improving individual health conditions (eg Falls prevention). It does not endorse exercise on referral schemes to promote physical activity where there is no underlying medical condition or risk. There is strong evidence however to demonstrate the importance of using health professionals to promote increased physical activity through brief interventions in primary care. The let s Get Moving Physical Activity Care Pathway is an evidence based behaviour change intervention based on the 2006 NICE physical activity public health intervention guidance and has been demonstrated to be both clinically and cost effective. 3. Conduct and Outcome of Review The review work undertaken during 2011 was conducted in two stages:- Stage 1 was carried out in the early part of the year to:- Identify the client base, including primary diagnosis / reason for referral (see Appendix 1) length and duration of attendance Review the capacity of the service to deliver additional sessions /service user places within the existing resources and consider the potential for the development of links to / provision of additional services Address concerns about the equipment This resulted in an urgent request to the board in March 2011 to fund the lease and maintenance costs for the gym equipment to ensure the viability of the Gym whilst a full review of the service was undertaken. Stage 2, which was carried out between July 2011 and January 2012, broadened the remit to include all the physical activity provision directly funded by the locality, but in particular set out to address the particular issues relating to the Community Gym identified in the Paper to the Board in August 2011. It undertook to do the following:- 1. Ensure gym equipment was available throughout the period of the review subsequently found not to be an issue as new equipment had been bought rather than leased. 2. Engage with Stakeholders to establish what they value about the current services, and what they would like to see improve. 3. An audit of the 16 week programme that had been put in place for new referrals to the Community Gym. 4. Discuss the feasibility of introducing the Let s get Moving Pathway in primary care. 5. Develop a Service Level Agreement and Service Specification for the Community Gym, in light of findings from the earlier actions and discussion with the provider, including extending provision to the whole Locality i.e.to areas outside Barrow. Engagement The engagement work that was carried out (see linked report Furness Locality Physical Activity Review Service user and Staff Survey January 2012) demonstrated how much all three programmes are appreciated by those who access them. Three things were mentioned consistently however; patients and staff would like to see a greater range of activities made available, they would like to see sessions held at different times, to accommodate those who work or have carer responsibilities, and some patients identified difficulty with transport
to get to services. In addition some clients interviewed at the Community Gym stated that they did not want a time limit imposed on attendance. Audit An audit of patients on the new 16 week programme was conducted in the last week of September 2011. This looked at patients referred in the week of 13 th June (whose expected discharge date would have been 26 th September) and those referred in the week of 13 th July (who should have had a half way review in the last week of August). It was apparent from this that the expectation that each individual would be reviewed at 8 weeks and again at 16 weeks was not taking place (of the total of 18 referrals over the two weeks, only 4 had had a mid way review, and none of the 10 referred in the week of 13 th June had had a 16 week review). It was clear from this and the notes provided by the lead instructor that, at that time, the service was struggling to conduct these reviews and no mechanism had yet been put in place to provide feedback to the referrers about an individual s progress. Let s Get Moving Physical Activity Pathway A discussion took place with several members of the Public Health team and Ruth Turner (a GP with particular interest and expertise in Physical Activity) about the ease with which the pathway might be implemented in primary care. It was felt that most GPs already have a good understanding of the relevance of encouraging all patients who are inactive to become more active and that the pathway and associated GP Physical Activity Questionnaire provides a useful structure to stimulate the provision of a brief intervention, and information and advice about what is available. The public health team have offered to do some training on implementation of the pathway and awareness raising with GPs about the resources on offer to patients. It has provisionally been agreed for this to be offered at the Protected learning Time event which is focused on Public Health. Service Level Agreement Currently, of the three services, only Pulmonary Rehab has a formal Service Specification. Consequently once the proposed Service Model for the Community Gym has been agreed a Service Specification and Service level Agreement needs to be formalised for both Cardiac Rehab and the Community Gym. 4. Proposed Service Model for the Community Gym. It is clear that all three services are highly valued by service users but that the gym has run for a number of years as an ongoing support service rather than an outcome focused rehabilitation service. This was in line with service models in place at the time that the Gym was established, but current models (both in physical and mental health) focus much more on self-management, empowerment and social inclusion, through providing individuals with the tools to manage their own condition. There is still a place for a supported programme of physical activity but this should provide those patients with an identified medical condition with a safe, time limited, introduction to physical activity in a supportive atmosphere before discharging them to maintain their physical activity independently i.e the full introduction of the 16 week programme for all clients. Clearly a move to this model would have consequences for the high level of users of the Community Gym who have no primary diagnosis and use the facility for the purposes of keeping fit or general health improvement. This group of patients will need to be supported, to identify how they can maintain their physical activity and/or replace the support that they clearly gain from attendance at the gym, and a period to make this transition. There will also be a greater expectation that referrers are clear about what outcomes they expect their patients to achieve from their attendance, in keeping with the physical activity pathway. Freeing up capacity in this way would:- Enable the Gym staff to support clients to develop personal objectives Ensure all clients receive a 8 & 16 week review Ensure all referrers receive feedback at the end of a client s programme Support clients into mainstream facilities or independent activity of their choice toward the end of their programme
It would also enable much closer links with existing services, and support the development of new interventions planned by the Physiotherapy Service for instance for those with Chronic Back Pain. Cardiac Rehabilitation COPD Chronic Back Pain Pulmonary Rehabilitation Physical Activity Service (Community Gym) Stroke Rehab MSK Short Term Assessment &Treatment 16 week Gym/rehab Programme Integration into Mainstream provision In discussions with the Provider Lead for the service, it has also been recognised that providing a single venue for the service, makes attendance for anyone outside Barrow (and for some who live in the town) extremely difficult, if not impossible. Consequently the service is currently investigating the possibility of developing a mobile service utilising alternative established premises in Barrow, Millom and elsewhere. If this is achieved, it will address the improvements requested through the Engagement process:- 1. Using established leisure facilities will widen the range of activities on offer, and for those people discharged at the end of a sixteen week programme may mean their transition to self directed exercise may be easier. 2. Some evening / weekend provision may be possible, facilitating attendance for those who work or have caring responsibilities. 3. Providing the service closer to home should ease the difficulties (and cost of) travel and facilitate greater adherence to exercise programmes. 5. Conclusion. All three services, Cardiac Rehabilitation, Pulmonary Rehabilitation and the Community Gym are valued by both referrers and patients. The service model currently in place at the Community Gym however is outdated and no longer fit for purpose. The service is also inaccessible to many patients within the locality. Engagement with Stakeholders has indicated three key improvements that they would like to see in the provision of these services and the revised service model and focused 16 week programme seeks to address these and adhere to recommendations made in the Department of Health Statement on Exercise Referral (March 2007).
6. Recommendations. That the Board approve 1. The development of a full specification for the Community Gym based on a 16 week outcome focused programme. 2. Approve the implementation of the Let s Get Moving Physical Activity Pathway in primary care. 7. Risks to implementation of these recommendations. The option of doing nothing was not considered. This would leave the provider with the risk of an unsustainable facility and potential redeployment of the staffing resource, through the delivery of an out dated model of provision. The locality would be commissioning an inequitable service and one not focused on supporting improved health outcomes for those with medical conditions known to benefit from increased physical activity. It is recognised however that there are a large number of users who have become heavily dependant on the service the community gym provides, and that a transition period must be built in to allow the existing service to support those clients to develop independent ways of maintaining their physical activity. 8. Monitoring and review Once the service specification is developed for the Community Gym, the key performance indicators will be described and these will guide the ongoing review of the clinical outcomes, productivity, efficiency and service capacity of the re-orientated service. Ongoing reviews of the other two programmes will also be necessary, to ensure that, the current level of provision of is sufficient (especially of Cardiac Rehab once the Heart Failure Service is fully operational) and that they are provided at times and in places across the locality to facilitate uptake.
Primary diagnosis and users (January 2011-data) APPENDIX 1 Attendanc e Average time in gym % of user base RANK Primary Diagnosis Cases Unspecified Diagnosis (Gym use 1 only) 322 18890 59 37% 2 Mental Illness 233 13655 59 26% 3 General Health improvement 94 5390 57 11% 4 Cardio Pulmonary 43 2325 54 5% 5 Respiratory 39 2225 57 4% 6 Diabetes 33 1525 46 4% 7 Stroke 28 2150 77 3% 8 Muscular Skeletal 25 2685 107 3% 9 Neurological Rehabilitation 25 1460 58 3% 10 Learning Disability 14 795 57 2% 11 Acquired Brain Injury 11 495 45 1% 12 Drug and Alcohol problems 10 600 60 1% 13 Eating disorder 2 120 60 0% 14 Cancer 2 105 53 0%