Workforce and job planning
In March 2018, there were 126 consultants on the SEM specialist register and 19 employing NHS Trusts (HEE August 2015). Other services employing SEM consultants are the defence medical services, public funded bodies, national governing bodies of sport, the independent sector and academic institutions. With the lack of full-time opportunities in the NHS many SEM consultants are working portfolio careers across both the private sector and the NHS. There are 48 SEM training posts across the UK, with 16 in London.
1. Musculoskeletal injury and musculoskeletal medicine
The Sport England Active People Survey (2015/6) found that 7.7 million people in England achieve 3 x 30 minutes (1.5 hours) of moderate intensity physical activity per week, translating to 11.55 million hours/week. This represents only 17.5% of the population achieving this very modest target. The aim is to increase that number of people doing regular exercise.
In the non-sporting active population, the incidence of musculoskeletal injury is approximately 2/1,000 hours of activity (1/1,000 for walking, 4/1,000 for jogging). Given these figures, it is expected that one in six people engaged in the recommended amount of physical activity will be injured each year. This equates to 1.25 million musculoskeletal injuries per year.
In the sporting population, the risk and incidence of injury is exponentially higher. In 1990, there were estimated to be 9.8 million sports injuries per year requiring medical attention. This represents approximately one injury per person per year in the 16–45 year old age group.
In total these two groups generate over 11 million injuries per year. Given that there are 209 CCGs in England, this would yield an average of approximately 53,000 musculoskeletal injuries per year, per CCG, assuming even distribution. Notably, these figures are for physical activity-related injuries only; the total burden of musculoskeletal injuries also includes accidents and work-related injuries. Many of these injuries will present to an emergency department, GP or private physiotherapist, but a significant proportion will require the attention of an experienced SEM physician. It would not be unreasonable to expect each CCG to have access to at least one consultant SEM physician to coordinate the work of treating such a large cohort of patients.
SEM physicians are highly trained in musculoskeletal medicine which is a core part of SEM training. Doctors trained in SEM are uniquely equipped to manage MSK injuries and conditions. MSK physicians manage over 80% of their patients without the need for referral to surgeons. In addition to their clinical skills, these doctors often use diagnostic ultrasound in the clinic and are trained in the use of injections and other non-surgical techniques in their treatment. Many SEM doctors work with sports teams and the techniques of diagnosis and treatment can be transferred to benefit the general population. An SEM physician is the ideal person to lead a multidisciplinary team providing musculoskeletal medicine services within the NHS. There are examples of SEM/MSK models of care in A fresh approach in practice , which outline the efficiencies and cost savings an SEM physician can bring in an NHS setting.
2. Exercise medicine
When considering the provision for exercise medicine, the need may be considerably higher. The Darzi report, High quality care for all, highlighted the need to transform the NHS into a ‘health service’ rather than an ‘illness service’, encompassing the principles of preventative medicine at its core, while the Foresight report has drawn attention to the unsustainable economic consequences of failing to address the nation’s physical inactivity.
Physical inactivity is heavily implicated in the aetiology of the most common and costly conditions affecting Western nations, namely cardiovascular and respiratory disorders, diabetes, obesity, dementia, frailty and falls in older people, and even some cancers. SEM physicians are required at a strategic level to coordinate campaigns to increase physical activity (as highlighted by NICE guidelines for certain musculoskeletal conditions), but more importantly to engage patients first-hand at a clinical level and facilitate health enhancing physical activity (HEPA) through exercise testing and prescription. All CCGs and hospital trusts will benefit from an SEM physician with these skills to co-ordinate physical activity programmes in low- and high-risk consumers.
The FSEM (UK), alongside Public Health England and Sport England, will be launching 'Moving Medicine' which will be the go-to physical activity brand in UK healthcare. The project will deliver an online evidence-based resource for all health professionals covering physical activity for chronic diseases and conditions and an active hospital pilot led by an SEM consultant which will be adoptable across the UK. The resource will be launched via the medical royal colleges in September 2018; there will also be a dedicated free access website at www.movingmedicine.org.uk .
The burden of musculoskeletal conditions and injuries, plus diseases related to physical inactivity, is considerable and growing. In addition to this, the laudable aim of increasing health-enhancing physical activity (HEPA) is beginning to make a real impact.
As HEPA increasingly becomes a part of DH strategy, exercise specialists with the ability to safely engage moderate and high-risk patients in HEPA will be needed for implementation at grass-roots level. With the urgency to create a more physically active nation, SEM specialists will also be required within CCGs to promote HEPA in the low-risk majority. The Faculty of Sport and Exercise Medicine UK provides a Membership Exam and a Specialty Training Pathway for both SEM physicians and SEM consultants.
There are 209 CCGs in England with similar organisational arrangements existing proportionately in the devolved nations. One consultant SEM physician in every CCG, while creating a critical mass of specialists able to begin the work, would still only represent one consultant SEM physician for every 250,000 people, which is the average population of a CCG.
Ongoing audit of the clinical workload of practising SEM physicians will enable accurate workforce planning, though in the short term an estimated range of 150–300 consultant SEM physicians in England alone (1 or 2 per CCG) represents a realistic starting point. Given the burden of musculoskeletal injury and the expanding role of exercise medicine, these consultants would expect to experience a significant workload.
The population of the UK is currently just under 64 million people. If we consider the whole of the UK, then a proportionate increase in this number would (according to population) yield a requirement in the range of 180–360 consultant SEM physicians within the UK. Given the current number of SEM trainees, it may take many years for this number of consultants to be trained.
It is worth noting that in the year 2000, the Australasian College of Sports Physicians (ACSP) estimated that their population of 21 million people would require a workforce of at least 200 senior sports physicians. If we extrapolated those figures to the UK for the sake of comparison, the figures would be closer to 600 consultant SEM physicians within the UK.
The job plan below is an example included as guidance and not intended to be prescriptive. Activities will vary according to population served, demographics and location. For further information, see the BMA/NHS Employers guidance from 2011.
Sport and exercise medicine (SEM) is a new specialty and therefore there is limited data on the need and demand, and the development of the workforce.
There are two components to SEM and both need to be considered and weighted when job planning.
Range of activities
SEM is an outpatient-based specialty and the consultant-led service can offer clinics in a variety of different areas. The new patient to follow-up ratio should be approximately 1:2. Consultation times should be approximately 30 minutes for a new patient and 15 minutes for a follow-up appointment. These figures may vary depending on the clinic type and on the complexity of the patient population seen.
SEM consultants are unlikely to have an acute on-call commitment but may be part of a musculoskeletal on-call team. Consultants are unlikely to have a GIM commitment or direct responsibility for inpatients. However, they may receive weekly requests for inpatient assessments (DCC). Other weekly activities include:
- junior staff training and mentoring (SPA)
- undergraduate teaching (SPA)
- research (SPA)
- service development/management (SPA)
- appraisal/CPD (SPA)
- audit (DCC).
The ratio of direct clinical care (DCC) to supporting professional activities (SPA) should be 7.5:2.5 but this may vary depending on the demands and requirements of the job.
ClinicsThere are a range of clinic activities within sports and exercise medicine, including:
Sports medicine clinic
Acute and chronic musculoskeletal injuries and medical problems related to participation in physical activity, exercise or sport.Exercise medicine clinic
Exercise testing and prescription, exercise ECG, VO 2 max, strength measurement, balance and training plans. To facilitate the use of exercise in the management of chronic medical conditions such as cardiac and pulmonary diseases, diabetes, obesity, osteoporosis and frailty in older people.Rapid access soft tissue clinic
The equivalent of a fracture clinic to an SEM physician. The clinic permits rapid access to a consultant SEM physician (via referrals from emergency departments) for acute soft tissue injuries related to exercise.Musculoskeletal clinic
A soft tissue clinic run by an SEM consultant can help reduce the burden of referrals to rheumatology and orthopaedics.Workplace wellness clinic
In conjunction with occupational health, consultant SEM physicians are ideally suited to lead a hospital or CCG wellness programme to improve the health of the workforce.Clinic procedures
This includes intra-compartmental pressure testing, injection treatments and musculoskeletal ultrasound.