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NHS exercise programmes a success with older people but not always evidence-based

Last week the Royal College of Physicians published a new audit on exercise provision in falls services across the UK. Some of the findings were, unfortunately, not unexpected!

This survey was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Physicians’ Clinical Effectiveness and Evaluation Unit (CEEU). It follows on from concerns raised in an earlier programme of work looking at older people’s experiences of falls prevention services in general and complements the findings from the recent report of the national audit of falls and bone health audit in older people 2010. The aim of the project was to obtain patients’ experiences of NHS run therapeutic exercise programmes to reduce falls. The patient questionnaire was supplemented by a survey of staff involved in the delivery of therapeutic exercise.

First, the good news!

  • Over 1,700 older people who had attended an NHS-run exercise programme to reduce falls shows that 96% felt the exercises were either beneficial or quite beneficial, and 95% were either satisfied or very satisfied with their exercise programme.

Now, the not so good news!

The implementation of evidence-based exercise interventions by healthcare providers is incomplete and varies widely. Overall, the types of exercises prescribed appear appropriate however, the frequency, intensity and duration of most programmes are low and do not appear to meet recommended guidance:

  • 86% of staff report low frequency of their exercise classes (once per week), well below recommended guidance.
  • Only 29% of patients returning questionnaires used ankle weights for targeted resistance training to reduce falls.
  • Only 52% of patients felt their exercise programme had been progressed.
  • 81% of patients attending a class indicated that this had lasted 12 weeks or less.
  • 73% of patients supervised at home indicated that their programme lasted for 3 months or less.

Not all staff delivering the exercise programmes to reduce falls are appropriately trained. Only 54% of sites had staff who had completed Postural Stability Instructor training and 41% of sites had staff who have completed Otago training.

Evidence shows older people are more likely to continue exercising in a class than on their own at home. However, responses from staff show there is lack of long term follow-up classes in the community that patients can attend. 9% of participating sites had no classes they could encourage patients to attend at the end of their NHS-run exercise programme and only 53% had two or more classes and many of these were not evidence based.

Key recommendations

  • Commissioners need to commission a local, integrated exercise continuum across health and local authorities/voluntary sector to ensure long term provision of evidence-based exercise programmes for reducing falls run by appropriately qualified staff.
  • The quality of training and delivery of exercise programmes for reducing falls needs to be monitored locally and nationally against the evidence base for delivering effective exercise programmes to reduce falls.

Dr Jonathan Treml, Consultant Geriatrician, University Hospitals Birmingham and RCP Associate Director for the National Audit of Falls and Bone Health said:

‘The right type of exercise is the single most effective way of reducing the risk of falls in older people. It is concerning that many local NHS services appear to provide exercise programmes that are of insufficient duration or intensity to assure benefit to this vulnerable group.’

So, even though we have had many guideline documents on the need for evidence based exercise, progression of the intensity or challenge of exercises and the need for effective delivery, we are still in a position where half those who are delivering exercise have not had up to date evidence based training and most are not being referred onto community based exercise to ensure effective duration. What are your thoughts?

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