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BLOG: Exercise Referral; Fit for Purpose?

Posted on 28 Feb 18

As many of you will know, a refresh of occupational standards is taking place in relation to the physical activity sector and included in that is Exercise Referral. With so many changes, it is hard for the average provider and fitness professional to keep up. For many of you, who have been in the industry some time, you will recall we have had many significant changes; from the advent of REPs, the QCF, the RQF and also CIMSPA. The last 20 years, overall, has been greatly positive for the fitness industry, with standards being raised, benchmarks set and recognition as a profession that really wasn’t there before.

CIMSPA have the backing of Sport England and various government groups and have been tasked with refreshing standards that form the basis of qualifications. This is an exciting prospect for our industry with the opportunity to gain chartered status and aid in differentiating career seniority and progression. CIMSPA are well underway with this and have formed a number of different stakeholder groups to help them to develop new standards.

This is a great time to reflect on what has worked well in our industry and what hasn’t and I will document my honest opinions in the hope that all influential stakeholders may take note.


The exercise referral standards and related qualification in many ways has not been refreshed for a number of years since it development by SkillsActive as a common unit qualification for the sector. Our industry’s take on qualification levels is an interesting one. With regards to the medical content, you must complete exercise referral before you can choose to progress on to a number of level 4 qualifications. While I wholeheartedly agree this is the right approach, I feel that all topics covered at level 4 should be covered in the exercise referral standards, if only at an introductory level.

For example, cardiac rehab, stroke rehab, neurological conditions and cancer among others are not really covered in the current exercise referral qualification. Therefore, for many learners their first ‘contact’ with these conditions is at level 4. My question is how can we really make someone a ‘specialist’ in that short space of time, without any previous knowledge to build on?

I feel exercise referral should be a strong foundation for any fitness professional wishing to join the exercise medicine or chronic disease space. A great example of foundation training can be found in both physiotherapy and medical training.

For example in medical school, we had 5 years training which included a wide range of modalities of teaching. We then have to complete 2 years of foundation training – these were jobs in a range of specialties, to provide a further broader base of knowledge before moving onto choosing your final specialty. Physiotherapists also have a similar rotational program, in the NHS. Most conditions do not come in isolation and many clients with one condition are likely to have a second or risk factors for others. A great example is diabetes, where a patient maybe obese, may also have hypertension, high cholesterol, ischaemic heart disease and in theory a higher risk of cancer. Therefore, we cannot learn about conditions in silos, they rarely present that way in real life.

While a concept like this will be difficult to enforce in the fitness industry, by ensuring exercise referral covers a wider range of conditions – we will ensure a stronger foundation on which to build level 4 on. The fitness professional with this potential level 3 in exercise referral could then also work with all the conditions if the client is ‘low risk’ rather than need a level 4. This then opens up accessibility, which is important when over 15million of the UK population have a chronic disease. At Active IQ this is something the team are passionate about and this has led to the integration of some very common chronic diseases into the new diploma in personal training qualification.

The other issue with traditional exercise referral is the funding cuts, which have occurred in many places. While there are some fantastic schemes out there, very few are evaluated. Without evaluation we cannot prove something work and therefore it is hard to get continued funding without proof! It is important to consistently collect and evaluate the following pieces of information:

  1. How many referrals have you had?
  2. What conditions were referred?
  3. What percentage of patients completed the scheme?
  4. One year following completion of the scheme, how many had raised and maintained their newfound physical activity levels?
  5. Also consider other health indicators or markers that you may wish to evaluate this could be physical health, psychological health or other.

While these may be suitable questions, designing an evaluation that is robust, gaining ethical approval and analysing the data, is a skill in itself. There are many universities’ that would be keen to aid in this. Leeds Beckett University and Loughborough are two universities that come to mind, that are exceptional in the field of physical activity.

Development of the qualification

My first involvement with standards and qualification development was as part of a group reviewing the exercise referral framework around 2010-2011. What struck me was the mix of people around the table at that time. Many of those in that room, ran training providers or were heavily influential in the sector. However, with regards to content, I would say there were probably only 2-3 people in the room that really could have contributed to the technical content. Reflecting on this, in future we must ensure that stakeholder groups are carefully considered as to what they bring to the table and any conflicts of interest recognised and managed.

If we want to work closely with the NHS and other health organisations and create more jobs for our students, then these organizations need more representation at these meetings. We should also try to learn from those working with great success in the chronic disease space in the traditional sense, but also the ‘disruptors’ doing innovative things well. It would be great to inject new blood and innovation into the stakeholder and curriculum development groups to really pull on the fantastic knowledge and experience gathered by a variety of people.


While awarding organisations are there to ensure consistency, there is still great variability in the delivery of exercise referral. An exercise referral qualification may be taught by an individual who has recently qualified and has minimal experience. In exercise referral we are working in the same space as health care professionals, the majority of whom are taught by tutors not just with the ‘piece of paper’ but also the experience to match. For example, at the medical school where I teach, you must have 5 years of full registration (6 years post graduation) and be working actively in a clinical setting in order to teach.

This ensures students are taught by those with experience and not just factual knowledge. Such experience helps to bring a topic to life with examples and case studies that a tutor without experience may not easily conjure.

It is also important for tutors to keep their knowledge and experience up to date. This can be difficult to achieve if the tutor is not working in that field regularly. At Active IQ we realise this and we are pushing to plug these shortfalls with updates regarding conditions, as well as our blogs and webinars. We have some fantastic resources coming in 2018 to help raise the standards further and aiming to keep our centres and tutors up to date.

Aim of qualification

Exercise referral was always aimed at those wanting to work in an exercise referral scheme. However, times have changed. Many students now doing Exercise Referral qualifications just want to work with those with chronic disease, in a variety of settings. I wonder if the title is still fit for purpose or whether we should be considering one that encompasses physical activity and chronic disease in the title?

Take Home Points

My recommendations to the sector:

  • Cover all level 4 conditions to some level in the Exercise Referral Qualification making this the true base or foundational element.
  • Ensure we engage the right people with the vocational and technical experience for curriculum development. I challenge whether that is the traditional fitness industry employer.
  • Have all Exercise Referral tutors qualified up to level 4 standard, ensure they work at least once a week in an appropriate setting whether in exercise referral or related schemes, clinical or an appropriate other that they can justify keeping up their skills.
  • Consider changing the title of the qualification.
  • Push and encourage soft skills including communication and behaviour change that are extremely important.
  • Introduce key principles of research, audit and evaluation to allow learner to effectively work in a scheme.

Keep in touch with us and industry updates on the Active IQ Facebook group.

Best wishes,

Dr Dane Vishnubala | Active IQ Chief Medical Advisor