Active Hospital Toolkit

Active Hospital Toolkit

Get physical activity on the agenda

Staff have valid concerns about prioritising physical activity in their practice

What’s the issue?

There are too many other things to do!

Finding a moment of opportunity – a patient open to a conversation about their physical activity behaviour, and a member of staff who could have that conversation with them – is a critical first step.

But staff will have other things they already need to talk to that patient about, and discussing moving more may not be their priority

“It may be less likely to happen because you have a certain agenda of what you need to get from your assessment and treatment plan that you’re going to do in that session.”  Outpatient Physio

“I think it’s the time. We have such a long list of things that, in a lot of cases, the priority of exercise starts to move a bit lower down that list.”  Physiotherapy Assistant

“You’re usually so busy doing everything else; making the beds, personal hygiene, getting beds ready for the next patients coming in, having that high demand on you. By the time you get to the discharge, which is usually the point where you go through everything, you tend to just go; here’s a booklet. There’s a bit of exercise and lifestyle advice in the back”. Cardiology Specialist Nurse

“You’ve got to cover all the essentials, then everything after that is added on. I think that’s why things like physical exercise have fallen by the wayside in the past, because we need to discuss many other important factors relating to their pregnancy”  Research Midwife

‘There’s an opportunity cost. What that means is that at a senior level we’ve got five, ten, 15 minutes with one patient to get through the most critical questions. The ones that we prioritise are what’s relevant right now. And I think that talking about public health aspects or longer term self-health aspects goes further down the list of what I’m going to cover before the acute aspects.’ Consultant

“I think part of it is not being aware of how much of an issue it is at times, because you’re dealing with something that seems more pressing. And equally, finding the time, opportunity and space to have a more appropriate discussion with them can be difficult.”  Foundation Doctor

“Let’s be honest, it may only take a minute, but when you’ve got 90 patients that’s an hour and a half. And the conversations would be, who pays for the staffing to stay late?”  Service Manager 

We just don’t have time!

The sense that there just isn’t time to talk about physical activity can be exacerbated by a recognition that a meaningful conversation, one that actually has a chance of helping a patient to consider changing their  behaviour, involves more than saying “You need to be more active”.

“What really needs to happen is a motivational interview. But if you’re clerking a patient in, you’ve not got time to do that. And once you’re on the ward, you’ve got 30 other patients to look after, and you’ve not got time to do that. And then, when they’re going to be discharged, the bed’s needed for the next patient. So, you’re not going to have time to do that. And ideally maybe a GP would do it. But they’ve got ten minutes and there’s lots of pressure there as well. I think these conversations get missed a lot.” Foundation Doctor

References:

  1. Hebert, E. T., Caughy, M. O. and Shuval, K. (2012) ‘Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review’, British Journal of Sports Medicine, 46, pp. 625–631. doi: 10.1136/bjsports-2011-090734.
  2. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

Telling staff how important physical activity is won’t help

One way of making conversations about physical activity a higher priority for staff might be to provide evidence of how beneficial it is for patients. The staff involved in the Active Hospitals pilot project were clear about the value of physical activity to patients.

What was less clear was its relationship to the priorities of their team, and their role in delivering those priorities.

‘I think everybody would see the value in this if everybody would agree that physical activity would improve health and in the long run would probably improve hospitalisation at some point and decrease the pressure on the system. I don’t think there would be a question for anybody to judge the value of physical activity. It’s just that there are some constraints in the acute setting which doesn’t allow these conversations to happen.’ Clinical Fellow Acute General Medicine

References:

  1. Hebert, E. T., Caughy, M. O. and Shuval, K. (2012) ‘Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review’, British Journal of Sports Medicine, 46, pp. 625–631. doi: 10.1136/bjsports-2011-090734.

2. Graham, R. C., Dugdill, L. and Cable, N. T. (2005) ‘Health professionals’ perspectives in exercise referral: implications for the referral process’, Ergonomics, 48(11–14), pp. 1411–1422. doi: 10.1080/00140130500101064.

3. Sherman, S. E. and Hershman, W. Y. (1993) ‘Exercise counseling: how do general internists do?’, Journal of general internal medicine, 8(5), pp. 243–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8505682 (Accessed: 30 July 2018).

4. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

Physical activity is only raised when it directly supports team priorities

Some conversations about physical activity are already on the agenda: those which are recognised as supporting team priorities and individual roles in delivering them. For example, in acute settings, staff are having conversations about physical activity when they:

  • contribute directly to clinical outcomes

‘We’ve got to see a relationship between the advice and the condition now.’  Consultant

“Activity is a massive thing in trauma and orthopaedics. Lots of people have had operations on legs or arms, and it’s important to keep them moving. People are moving around straightaway. It’s kind of a given. So I have a lot of conversations with people about getting up out of bed, mobilising, doing their exercises.” Foundation Doctor

  • help people get back to a baseline (rehabilitation)

‘For me, and I think probably for a lot of medical people, getting the information is, what can you do up until now? Something along the lines of: Can you do stairs? Can you walk out of your house? Can you get to your toilet? Have you fallen over? Do you use a walking stick? The questions tend to be either not asked or, if they are asked, what is your current level of functioning? And I think that is the main framing for how we estimate movement or talk about movement in the acute setting.’ Consultant

  • speed up discharge

“We would come onto the ward and then we’d see how many people are expected to come in versus how many people were going to come out again. We had to think very quickly and prioritise very quickly about who we were going to see first just to get patient throughput.” Outpatient Physio

Other kinds of conversation about physical activity – in particular, conversations about how increased levels of physical activity might contribute to patient wellbeing after discharge – are less likely to be discussed.

“The information you want to gather is: what you can do at home, how far off from that you are and how quickly can we get you back to that level again. That’s it basically. I don’t think I’ve ever even suggested people do more physical activity to actually improve their health more than what it is”.  Clinical Fellow Acute General Medicine

“She’s going to community hospital for rehab and we’re getting them ready for that. We’ve got her to the point where the patient is happy to do that exercise, so in my mind we’ve hit that bridge. Now she’s going to be developed further when she goes to rehab. So that’s beyond our point.”  Nursing Assistant 

“I always felt I was short-changing people because I could have said a lot more about getting active and reducing the risk of any other vascular problems. It’s just the time wasn’t there. “ Outpatient Physio

Finding a moment of opportunity – a patient open to a conversation about their physical activity behaviour, and a member of staff who could have that conversation with them – is a critical first step.

But staff will have other things they already need to talk to that patient about, and discussing moving more may not be their priority

“It may be less likely to happen because you have a certain agenda of what you need to get from your assessment and treatment plan that you’re going to do in that session.”  Outpatient Physio

“I think it’s the time. We have such a long list of things that, in a lot of cases, the priority of exercise starts to move a bit lower down that list.”  Physiotherapy Assistant

“You’re usually so busy doing everything else; making the beds, personal hygiene, getting beds ready for the next patients coming in, having that high demand on you. By the time you get to the discharge, which is usually the point where you go through everything, you tend to just go; here’s a booklet. There’s a bit of exercise and lifestyle advice in the back”. Cardiology Specialist Nurse

“You’ve got to cover all the essentials, then everything after that is added on. I think that’s why things like physical exercise have fallen by the wayside in the past, because we need to discuss many other important factors relating to their pregnancy”  Research Midwife

‘There’s an opportunity cost. What that means is that at a senior level we’ve got five, ten, 15 minutes with one patient to get through the most critical questions. The ones that we prioritise are what’s relevant right now. And I think that talking about public health aspects or longer term self-health aspects goes further down the list of what I’m going to cover before the acute aspects.’ Consultant

“I think part of it is not being aware of how much of an issue it is at times, because you’re dealing with something that seems more pressing. And equally, finding the time, opportunity and space to have a more appropriate discussion with them can be difficult.”  Foundation Doctor

“Let’s be honest, it may only take a minute, but when you’ve got 90 patients that’s an hour and a half. And the conversations would be, who pays for the staffing to stay late?”  Service Manager 

The sense that there just isn’t time to talk about physical activity can be exacerbated by a recognition that a meaningful conversation, one that actually has a chance of helping a patient to consider changing their  behaviour, involves more than saying “You need to be more active”.

“What really needs to happen is a motivational interview. But if you’re clerking a patient in, you’ve not got time to do that. And once you’re on the ward, you’ve got 30 other patients to look after, and you’ve not got time to do that. And then, when they’re going to be discharged, the bed’s needed for the next patient. So, you’re not going to have time to do that. And ideally maybe a GP would do it. But they’ve got ten minutes and there’s lots of pressure there as well. I think these conversations get missed a lot.” Foundation Doctor

References:

  1. Hebert, E. T., Caughy, M. O. and Shuval, K. (2012) ‘Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review’, British Journal of Sports Medicine, 46, pp. 625–631. doi: 10.1136/bjsports-2011-090734.
  2. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

One way of making conversations about physical activity a higher priority for staff might be to provide evidence of how beneficial it is for patients. The staff involved in the Active Hospitals pilot project were clear about the value of physical activity to patients.

What was less clear was its relationship to the priorities of their team, and their role in delivering those priorities.

‘I think everybody would see the value in this if everybody would agree that physical activity would improve health and in the long run would probably improve hospitalisation at some point and decrease the pressure on the system. I don’t think there would be a question for anybody to judge the value of physical activity. It’s just that there are some constraints in the acute setting which doesn’t allow these conversations to happen.’ Clinical Fellow Acute General Medicine

References:

  1. Hebert, E. T., Caughy, M. O. and Shuval, K. (2012) ‘Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review’, British Journal of Sports Medicine, 46, pp. 625–631. doi: 10.1136/bjsports-2011-090734.

2. Graham, R. C., Dugdill, L. and Cable, N. T. (2005) ‘Health professionals’ perspectives in exercise referral: implications for the referral process’, Ergonomics, 48(11–14), pp. 1411–1422. doi: 10.1080/00140130500101064.

3. Sherman, S. E. and Hershman, W. Y. (1993) ‘Exercise counseling: how do general internists do?’, Journal of general internal medicine, 8(5), pp. 243–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8505682 (Accessed: 30 July 2018).

4. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

Some conversations about physical activity are already on the agenda: those which are recognised as supporting team priorities and individual roles in delivering them. For example, in acute settings, staff are having conversations about physical activity when they:

  • contribute directly to clinical outcomes

‘We’ve got to see a relationship between the advice and the condition now.’  Consultant

“Activity is a massive thing in trauma and orthopaedics. Lots of people have had operations on legs or arms, and it’s important to keep them moving. People are moving around straightaway. It’s kind of a given. So I have a lot of conversations with people about getting up out of bed, mobilising, doing their exercises.” Foundation Doctor

  • help people get back to a baseline (rehabilitation)

‘For me, and I think probably for a lot of medical people, getting the information is, what can you do up until now? Something along the lines of: Can you do stairs? Can you walk out of your house? Can you get to your toilet? Have you fallen over? Do you use a walking stick? The questions tend to be either not asked or, if they are asked, what is your current level of functioning? And I think that is the main framing for how we estimate movement or talk about movement in the acute setting.’ Consultant

  • speed up discharge

“We would come onto the ward and then we’d see how many people are expected to come in versus how many people were going to come out again. We had to think very quickly and prioritise very quickly about who we were going to see first just to get patient throughput.” Outpatient Physio

Other kinds of conversation about physical activity – in particular, conversations about how increased levels of physical activity might contribute to patient wellbeing after discharge – are less likely to be discussed.

“The information you want to gather is: what you can do at home, how far off from that you are and how quickly can we get you back to that level again. That’s it basically. I don’t think I’ve ever even suggested people do more physical activity to actually improve their health more than what it is”.  Clinical Fellow Acute General Medicine

“She’s going to community hospital for rehab and we’re getting them ready for that. We’ve got her to the point where the patient is happy to do that exercise, so in my mind we’ve hit that bridge. Now she’s going to be developed further when she goes to rehab. So that’s beyond our point.”  Nursing Assistant 

“I always felt I was short-changing people because I could have said a lot more about getting active and reducing the risk of any other vascular problems. It’s just the time wasn’t there. “ Outpatient Physio

You have much less time and you have to ask absolutely the critical questions. So, what’s interesting is: where, in the hierarchy of important things to know about, does movement come in?

Consultant

What does this mean in practice?

You may find some of the following suggestions helpful

Don't frame it as ‘another thing you have to do’!

It can be important to frame the topic in the right way to get help staff to engage.

‘The more things you have on a list, the more each aspect becomes something you have to do. If all you have to do is make a diagnosis, you spend a bit of time on it. But when you’re told you need to make sure they’ve had a VTE assessment, cognition, sepsis, drug charts checked, pressure areas checked, you’ve talked to them about medications, ideas, concerns, expectations, side effects of medications, follow up, etc. Then smoking, alcohol, exercise. It can become perfunctory and everything has less time. And therefore, you do start to wonder, if I’m just saying something in passing is there benefit in that? And therefore, you put it to the side and you deal with the acute things.’ Consultant

A collaborative approach, starting from an understanding of the reality of their working context, their priorities and roles within that context, and the steps they were already taking to have conversations with patients about physical activity can be a useful way to start.

Find out how physical activity can add further value against service priorities and staff’s roles in delivering them

Encouraging physical activity may already be on the agenda when it is recognised as supporting team priorities and individual roles in delivering them.

There may be other, unrecognised, value that physical activity could add which (given the time and space) staff can help to identify.  

“If you’ve got your patients out walking around, this is where you’re going to benefit them, improve patient feedback and make them more motivated. Maybe get them out of hospital quicker and reduce pressure sores.”  Cardiology Specialist Nurse

“It also means that they get to chat to people and interact rather than just being on their own or by their bed for the duration of their stay”.  Foundation Doctor

‘Some staff would perceive, oh, it’s another extra thing to do. In the mornings when the carers have to wash and dress patients, just prompting them to ask the patients; what do they do at home normally? And if they get the answer that they do it by themselves in the chair, then just supervise them to get onto the chair and leave it for the patient to do themself. It’s a functional activity, a functional exercise, which helps the staff to have more time for themselves, for their breaks, for the other activities.’ Acute General Medicine Physiotherapist

“It wasn’t until I joined this team and experienced all the information in the sessions, that you think, of course we should be having these conversations with women”.  Midwife

Encouraging patients to increase their levels of physical activity may also have a much wider impact on their well-being, with consequent benefits for the system as a whole.

‘I think the bit that’s missing the most is when movement isn’t a problem right now. We aren’t good, I’m certainly not good and I don’t think the system is good, at saying: if you do this or we give you this resource now, such as a physiotherapist, it will build up your resilience such that you will be more capable of self-determining later on. It helps the system because you’re less likely to need a lot more help further down the line.’ Consultant

For individual staff, however, these wider benefits may prove harder to link to the day-to-day priorities they have to address.

Tap into personal motivations

Staff bring their own personal beliefs, values and experiences to their work. For some, that will mean a personal commitment to the value of physical activity. With support, these staff may become physical activity champions, helping to get physical activity onto the agenda of their colleagues.

“Exercise just made me feel so much better. I felt I could pass this feeling onto patients to empower them”. Staff Nurse

There may be some value in asking staff to think about what physical activity means in their own lives.

For some other staff groups, the opportunity to have a different kind of conversation with patients may be motivating.

“Most of our receptionists here enjoy the face-to-face. They do find that because of the nature of the service they get a lot of negativity ‘how long for my appointment? I’ve been waiting an hour’. I think they would get a lot of satisfaction being able to spend some time with patients.”  Service Manager 

Make having the conversation easier

Although it is useful to help staff see the value of conversations about physical activity, it may also be important to look at ways of reducing the cost of those conversations – that is, the amount of time needed for a meaningful conversation with a positive outcome.

“We have a time pressure of forty-five minutes with the patient. Sometimes physical activity is in danger of being lost. I find strategies like five-minute, one-minute conversations is quite helpful. “ Outpatient Physio

“You can do a little bit or you can do a lot more. You went in to: barriers are up, we’ve already got enough work to do, we can’t take on anymore, we’ll listen to you, but actually, we need to get on with our day.   When we explained the process, spent time with them and talked it through, they realised it’s quite easy, it’s obvious and they were completely on-board.”  Research Midwife

Making the conversation easier is about supporting the development of staff skills and confidence.

Look closely at the team’s culture and practices

Staff agendas usually reflect their understanding of the priorities of their team and their own role in delivering those priorities. So it may be worth looking closely at what those team priorities are, who sets them, and how they are communicated.

“If there’s a culture in your hospital that we want to promote physical activity, that is one thing that gives you permission to push it a little bit further.”  Outpatient Physio

“It does tend to come from the top down, I think with these things. If it’s incredibly important to the Consultants then it’s incredibly important to the juniors”.  Foundation Doctor

How are those priorities embedded in team practices, such as staffing patterns. For example, does the allocation of nursing assistants to patients make it feasible for those nursing assistants to encourage and support individual patients in keeping active?

What changes to team practices could make conversations about physical activity more efficient – for example, if groups of patients could be brought together to hear information about physical activity.

“If you could get a little round-up of patients, take them off to the day room and give a little lecture on lifestyle and advice, instead of going about it one by one. I think that would be really good”.  Cardiology Specialist Nurse

“They’ve got the background information before they come in, so we can just top it up as an individual when they come and see us.”  Midwife

Teams vary in the way that they operate and so in what’s needed to bring about change.

“The initial conversations would be how the dynamic of the actual service works. I think that’s a really tough ask on each of the services. Unless you know what the service requires in terms of its hierarchy, staffing and who would be the best-placed person to implement positively. Is it a particular consultant who actually is extremely well-respected by his team or the wider team and therefore that trickles through as very positive? Or, do you go to the service manager who manages the administration team where this may be perceived as a clinical discussion and therefore receive a less positive response. I think understanding this is where the success lies. I feel it will be tough to manage without this consideration”.Service Manager  

Reference:

  1. Johnson, M. J. and May, C. R. (2015) ‘Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews’, BMJ Open, 5(9), p. e008592. doi: 10.1136/bmjopen-2015-008592.
  2. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

 

 

It can be important to frame the topic in the right way to get help staff to engage.

‘The more things you have on a list, the more each aspect becomes something you have to do. If all you have to do is make a diagnosis, you spend a bit of time on it. But when you’re told you need to make sure they’ve had a VTE assessment, cognition, sepsis, drug charts checked, pressure areas checked, you’ve talked to them about medications, ideas, concerns, expectations, side effects of medications, follow up, etc. Then smoking, alcohol, exercise. It can become perfunctory and everything has less time. And therefore, you do start to wonder, if I’m just saying something in passing is there benefit in that? And therefore, you put it to the side and you deal with the acute things.’ Consultant

A collaborative approach, starting from an understanding of the reality of their working context, their priorities and roles within that context, and the steps they were already taking to have conversations with patients about physical activity can be a useful way to start.

Encouraging physical activity may already be on the agenda when it is recognised as supporting team priorities and individual roles in delivering them.

There may be other, unrecognised, value that physical activity could add which (given the time and space) staff can help to identify.  

“If you’ve got your patients out walking around, this is where you’re going to benefit them, improve patient feedback and make them more motivated. Maybe get them out of hospital quicker and reduce pressure sores.”  Cardiology Specialist Nurse

“It also means that they get to chat to people and interact rather than just being on their own or by their bed for the duration of their stay”.  Foundation Doctor

‘Some staff would perceive, oh, it’s another extra thing to do. In the mornings when the carers have to wash and dress patients, just prompting them to ask the patients; what do they do at home normally? And if they get the answer that they do it by themselves in the chair, then just supervise them to get onto the chair and leave it for the patient to do themself. It’s a functional activity, a functional exercise, which helps the staff to have more time for themselves, for their breaks, for the other activities.’ Acute General Medicine Physiotherapist

“It wasn’t until I joined this team and experienced all the information in the sessions, that you think, of course we should be having these conversations with women”.  Midwife

Encouraging patients to increase their levels of physical activity may also have a much wider impact on their well-being, with consequent benefits for the system as a whole.

‘I think the bit that’s missing the most is when movement isn’t a problem right now. We aren’t good, I’m certainly not good and I don’t think the system is good, at saying: if you do this or we give you this resource now, such as a physiotherapist, it will build up your resilience such that you will be more capable of self-determining later on. It helps the system because you’re less likely to need a lot more help further down the line.’ Consultant

For individual staff, however, these wider benefits may prove harder to link to the day-to-day priorities they have to address.

Staff bring their own personal beliefs, values and experiences to their work. For some, that will mean a personal commitment to the value of physical activity. With support, these staff may become physical activity champions, helping to get physical activity onto the agenda of their colleagues.

“Exercise just made me feel so much better. I felt I could pass this feeling onto patients to empower them”. Staff Nurse

There may be some value in asking staff to think about what physical activity means in their own lives.

For some other staff groups, the opportunity to have a different kind of conversation with patients may be motivating.

“Most of our receptionists here enjoy the face-to-face. They do find that because of the nature of the service they get a lot of negativity ‘how long for my appointment? I’ve been waiting an hour’. I think they would get a lot of satisfaction being able to spend some time with patients.”  Service Manager 

Although it is useful to help staff see the value of conversations about physical activity, it may also be important to look at ways of reducing the cost of those conversations – that is, the amount of time needed for a meaningful conversation with a positive outcome.

“We have a time pressure of forty-five minutes with the patient. Sometimes physical activity is in danger of being lost. I find strategies like five-minute, one-minute conversations is quite helpful. “ Outpatient Physio

“You can do a little bit or you can do a lot more. You went in to: barriers are up, we’ve already got enough work to do, we can’t take on anymore, we’ll listen to you, but actually, we need to get on with our day.   When we explained the process, spent time with them and talked it through, they realised it’s quite easy, it’s obvious and they were completely on-board.”  Research Midwife

Making the conversation easier is about supporting the development of staff skills and confidence.

Staff agendas usually reflect their understanding of the priorities of their team and their own role in delivering those priorities. So it may be worth looking closely at what those team priorities are, who sets them, and how they are communicated.

“If there’s a culture in your hospital that we want to promote physical activity, that is one thing that gives you permission to push it a little bit further.”  Outpatient Physio

“It does tend to come from the top down, I think with these things. If it’s incredibly important to the Consultants then it’s incredibly important to the juniors”.  Foundation Doctor

How are those priorities embedded in team practices, such as staffing patterns. For example, does the allocation of nursing assistants to patients make it feasible for those nursing assistants to encourage and support individual patients in keeping active?

What changes to team practices could make conversations about physical activity more efficient – for example, if groups of patients could be brought together to hear information about physical activity.

“If you could get a little round-up of patients, take them off to the day room and give a little lecture on lifestyle and advice, instead of going about it one by one. I think that would be really good”.  Cardiology Specialist Nurse

“They’ve got the background information before they come in, so we can just top it up as an individual when they come and see us.”  Midwife

Teams vary in the way that they operate and so in what’s needed to bring about change.

“The initial conversations would be how the dynamic of the actual service works. I think that’s a really tough ask on each of the services. Unless you know what the service requires in terms of its hierarchy, staffing and who would be the best-placed person to implement positively. Is it a particular consultant who actually is extremely well-respected by his team or the wider team and therefore that trickles through as very positive? Or, do you go to the service manager who manages the administration team where this may be perceived as a clinical discussion and therefore receive a less positive response. I think understanding this is where the success lies. I feel it will be tough to manage without this consideration”.Service Manager  

Reference:

  1. Johnson, M. J. and May, C. R. (2015) ‘Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews’, BMJ Open, 5(9), p. e008592. doi: 10.1136/bmjopen-2015-008592.
  2. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

 

 

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