Duty of care

Duty of care is a legal obligation imposed on a doctor requiring, via the Bolam test,9 that their actions conform to those of a responsible body of professional opinion, even if others have a different opinion. More recently, the Bolitho v City and Hackney Health Authority case, entitled a judge to choose between two bodies of expert opinion and reject an opinion, which is ‘logically indefensible’.10

In the UK, duty of care, in the form of National Institute for Health and Clinical Excellence and Royal College guidelines, currently represents an evidence-based responsible body of professional opinion relating to clinical care. Medical ethics, including patient autonomy, non-maleficence, beneficence and informed consent, guide our medical care, when guidelines are not always appropriately applied. Medical defence unions providing medical indemnity repeatedly recommend that our professional and clinical decisions be documented in medical records and note keeping, including those situations when guidelines are not suitable.

Numerous responsible bodies of professional opinion have recognised the extensive evidence base, cost-effectiveness and importance of physical activity promotion as a primary prevention and secondary treatment for various diseases. Physical activity promotion features in 39 national guidelines (table 1), even excluding physical activity–specific guidelines. On this basis, if a doctor managing a patient with any of these diseases has not followed these guidelines and advised or signposted appropriately on physical activity, then it is possible that medical negligence has ensued. Furthermore, would it be ‘logically indefensible’ for doctors not to promote physical activity for these patients, regardless of their personal opinions and learning needs?

Given the technology and functionality of primary care computerised medical records, it would be relatively cheap and simple to embed such recommendations within standard note keeping templates to help guide practitioners through the forgotten and fundamental basis of these guidelines, ensure medicolegal defensibility, should the need arise, and reduce the potential risk of medical-negligence proceedings.

Critics will argue that physical activity promotion is a lifestyle choice, however, so are smoking and alcohol consumption and yet these are medically accepted risk factors worthy of our clinical behaviour change efforts and consultation time. In many countries around the world, exercise and tailored physical activity are used by trained Sport and Exercise Medicine (SEM) specialists working within multidisciplinary teams, to both treat and prevent various chronic diseases. Unfortunately, in the UK, there are many patients with chronic diseases, risk factors and comorbidities, who are essentially excluded from physical activity. Their attending doctors invariably lack the knowledge to provide them with necessary physical activity and behaviour change advice (or exercise prescription), are fearful of perceived physical activity risks and resulting litigation, or cannot access specialist National Health Service (NHS) SEM services, despite the existence of an emerging trained specialist SEM workforce seeking NHS employment. Ironically, these patients stand to gain the most from intervention (as does the NHS), yet remain unlikely to receive this advice, being advised to rest, risking further health and well-being detriment.

The responsibility for delivering Exercise Medicine in the UK is left in the hands of doctors who do not understand the basic science behind physical activity, benefits, risks, doses or methods to change complex physical inactivity behaviours. Why can we rightly refer to a dietitian for assistance with disordered eating habits and still not refer to an SEM specialist on the NHS for specialist Exercise Medicine care, when appropriate?

An institutional and educational problem

General Medical Council (GMC) guidance on ‘Good Medical Practice’ suggests that doctors should ‘protect and promote the health of patients and the public’.11 Yet physical activity promotion remains un-rewarded in primary care,6 Exercise Medicine is not on the core curriculum of many medical schools12 and most doctors are not trained to deliver physical activity promotion and behaviour change.

Regulatory authorities, such as the GMC, are now responsible for standards of medical education, in a position to focus future medical practice and ensure that preventive medicine and wellness promotion feature as highly as treatment of illness in the future. The GMC regulates undergraduate medical education and, regrettably, physical activity does not feature as a curricula requirement (Tomorrow's Doctors 2003 and 2009). In addition, it is not specifically covered in GMC medical school quality assurance reviews. The GMC, like doctors, may have a responsibility and duty of care to the public and their future members to review medical school curricula requirements relating to the promotion of health and prevention of disease with greater emphasis and guidance for physical activity education. Only then, will future doctors be optimally educated to deliver behaviour and lifestyle change for the prevention and treatment of illness, which are embedded within ever-increasing guidelines.

UK public health strategy

In the UK NHS, the introduction of the Responsibility Deal and GP commissioning, will probably place more health strategy decisions in the hands of corporate stakeholders and ‘willing providers’. Hidden agendas, such as profitability, may influence important public health rationing decisions and perceived un-profitable physical activity promotion and Exercise Medicine may well continue to suffer. Unfortunately, very few private stakeholders stand to benefit from better population health, which, worryingly, means that corporate agendas could direct national health strategies and leave Exercise Medicine largely aspirational and marginalised. In brief, for the current evidence base to be translated into commissioned NHS Exercise Medicine services in the UK, there is an urgent need for strong evidence to demonstrate cost-effectiveness, improved patient care pathways and outcomes for such services.

Summary

Medical science has shown that low cardiorespiratory fitness (resulting from sedentary behaviour) is one of, if not, the most important risk factors for all-cause mortality,13 yet clinical practice, medical education and public health strategy continue to focus on all other risk factors except sedentary behaviour. Physical activity promotion is embedded within a large number of ever-increasing clinical guidelines with strong supporting evidence, both medical and cost-effective, delivering positive clinical messages and medicolegal responsibility to healthcare practitioners.

Is it possible that there may be a time when a lawyer cross examines a doctor in the witness stand, asking why they did not address their sick or dead patients' physical inactivity, citing clinical guidelines, because it is known to be one of the highest modifiable risk factors for morbidity and mortality? Physical activity promotion is one of the first treatment recommendations in numerous clinical guidelines with a good reason and should no longer be medically neglected.

Physical activity failings are institutionally embedded within our environment, medical practice, education and culture. The public are being let down on physical activity promotion, treatment choices (eg, Exercise Medicine), preventive medicine, the sedentary environment, corporate influences, a lack of physically active medical role models and failed by a lack of funding for physical activity and inactivity research. All resulting in between approximately 27–59 million14 people in the UK alone, when measured subjectively and objectively, respectively,15 literally sitting in a pre-disease or disease state caused by physical inactivity – probably the biggest silent killer of our times.