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Medico-legal - Make exercise referrals safe

Dr Michael Devlin advises GPs to be cautious when referring patients for fitness treatment.

GPs are increasingly referring patients for exercise therapy but could face claims or complaints against them if the referral is to an unqualified fitness instructor and the patient comes to harm due to an inappropriate exercise regime.

According to research by the Mental Health Foundation published in February 2008, 22 per cent of GPs questioned said they prescribe exercise therapy to people with mild or moderate depression. Three years ago only 5 per cent of respondent GPs did this.

Treatment option
Such surveys may reflect a growing awareness of exercise referral as a treatment option in general practice. In 2006, NICE published public health guidance on ways to increase the population's levels of physical exercise and when it may be appropriate to make exercise referrals.

It recommended that: 'Practitioners, policy-makers and commissioners should only endorse exercise referral schemes to promote physical activity that are part of a properly designed and controlled research study to determine effectiveness.'

MDU members have asked whether they could be criticised by the GMC for referring patients for exercise programmes, particularly when they do not know what the programme involves, or where sports professionals are not registered with appropriate regulatory bodies.

The GMC's guidance on referrals in paragraph 55 of 'Good Medical Practice' (2006) states: 'You must be satisfied that any healthcare professional to whom you refer a patient is accountable to a statutory regulatory body or employed within a managed environment. If they are not, the transfer of care will be regarded as delegation, not referral. This means you remain responsible for the overall management of the patient, and accountable for your decision to delegate.'

The GMC has indicated that it would have no concerns about a GP referring a patient to a person registered with the Register of Exercise Professionals (REP). The DoH also produced a national quality assurance framework in 2001 on exercise referral programmes. This recommends referring patients to fitness instructors qualified as advanced Level 3 instructors with the REP.

Ethical duties
GPs have an ethical duty to recognise and work within the limits of their competence. The MDU advises GPs without specialist knowledge of sport and exercise medicine that it is more appropriate to 'recommend' exercise to a patient, rather than 'prescribing' it or referring them to an unregistered professional.

GPs who are asked to complete 'fitness' forms for patients about to start supervised exercise courses should also bear in mind paragraph 63 of Good Medical Practice which states: 'You must be honest and trustworthy when writing reports, and when completing or signing forms, reports or other documents.'

If you are not expert on this, you may think it more prudent to certify that you know no reason why the patient should be 'unfit to exercise'.

  • Dr Devlin is a medico-legal adviser with the Medical Defence Union
  • Register of Exercise Professionals www.exerciseregister.org or call 020 8686 6464

Scenario
An overweight patient with a history of hypertension visited her GP for advice on weight loss. The GP recommended gentle exercise and suggested the patient join her local health club.

Unfortunately, while the patient was taking part in an exercise class, she felt faint and experienced heart palpitations and was taken to hospital for a precautionary ECG.

The patient later complained to the GP that she should have been warned explicitly about the risks of taking part in energetic exercise. The GP sympathised that the patient had been through such an upsetting experience and explained that although there was no reason why she should not take part in gentle exercise, she needed to be aware of warning signs that an activity was too energetic. The GP discussed these with the patient and she agreed to persevere with the health club. The GP suggested to her that before she begins she should consider seeking advice from a suitably qualified fitness instructor about the most appropriate exercises.

This scenario is fictitious, but based on cases from the MDU's files. GPs with specific concerns should contact their medical defence organisation for advice.

Learning points

  • The GMC expects GPs to refer patients to an exercise professional registered with a statutory body (such as the Register of Exercise Professionals).
  • If 'referring' a patient to an exercise programme, bear in mind the guidance from NICE and the NHS national quality assurance framework.
  • Be cautious when asked to sign a certificate to say patients are fit to take part in particular activities if it might be preferable to certify that you 'know of no reason why the patient should not be fit for' the particular activity.
  • Consider implementing a practice protocol on prescribing or recommending exercise.

Resources

Mental Health Foundation information booklets: How exercise can help beat depression for patients and Exercise referral and the treatment of mild or moderate depression for GPs and healthcare practitioners.

Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling, March 2006

Exercise Referral Systems: A National Quality Assurance Framework, DoH, 2001

Good Medical Practice (2006).

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