Increasing our understanding of the state of care for people with lung conditions will help shape care in the future

Rachael Andrews, Deputy Programme Manager at the National Asthma and COPD Audit Programme (NACAP), explains how the audit helps to improve respiratory care.

COPD and asthma are the most common lung diseases in the UK with approximately 6.6 million diagnosed cases and 200,000 admissions to hospital each year. Although improvements have been made in respiratory care, there remains work to do as a historic lack of continuous data has made it difficult to strategically improve services.

This is where the National Asthma and COPD Audit Programme (NACAP) comes in. Commissioned by the Healthcare Quality Improvement Partnership (HQIP), NACAP aims to improve care and outcomes for people with asthma and COPD by conducting national audits of respiratory services to create an accurate picture of respiratory care. Most importantly, NACAP encourages and supports multidisciplinary teams to use their data to drive change and identify areas for improvements.

One of the most pressing issues in respiratory care is increasing access to pulmonary rehabilitation (PR). PR is a life changing package of exercise and support to manage lung disease more effectively and which has proven to be more effective than a lot of drug based interventions. Many patients report significant improvement following a course of PR, whether they have been referred for general improvement of their COPD or after an admission to hospital for COPD to aid recovery. The fact that PR is now a key feature in the Long Term Plan, plus a full PR audit being funded shows that this has been recognised.

The Taskforce for Lung Health recommends that access to PR is improved, so that every person with an MRC breathlessness score of grade 2 and above is identified, referred to and has the opportunity to complete a PR programme.  As a member of the Taskforce for Lung Health, NACAP (as part of the Royal College of Physicians), is working with clinicians, our own patient panel and the Taskforce to support increased quality of and access to PR, and NACAP data is now used to inform the Taskforce for Lung Health PR data tracker.

NACAP’s PR audit uses data submitted by services themselves to highlight areas of good practice and where improvement is needed. It then actively works with services to use their data to drive national and local change and improvement.

The 2019 pulmonary rehabilitation (PR) audit report has given us some insights into clinical care, service provision and patient outcomes.

Findings from the 2019 report
Results from NACAP’s PR clinical and organisational 2019 audits

Results from NACAP’s PR clinical and organisational 2019 audits* were published in December 2020. The participation rate for these audits (just under 90% of services in England, Scotland and Wales) is evidence of PR service dedication to improve and provide the best care for their patients.

PR programme completion rates and patient outcomes experienced following PR also give cause for celebration. 67% of patients enrolled for PR (3% short of the national target) go on to complete their programme, with the majority experiencing improvements in their exercise capacity and health status matching results from international research trials. This shows that many PR services are providing patients with the support and encouragement they need to complete their programme and achieve the improvement desired.

That being said, the results do present challenges for PR services. These include:

  • People from the poorest parts of society or with mental health issues were less likely to complete their PR programme, showing they need more support.
  • Only 34% of services provided transport, meaning that sicker or more vulnerable patients may find it all the more difficult to attend and complete their PR programme.
  • Despite national guidance that patients with MRC grades 3-5 or who have been admitted to hospital with a worsening of their COPD should receive an immediate referral for PR, 12% of PR services in England were not accepting referrals for MRC grade 5 and only 5.2% of referrals received were for patients after an admission to hospital for their COPD.
  • 46% of patients referred for PR are still not starting PR within the 90-day target.

These are all things that PR services must acknowledge and continue to even out. We would like to encourage PR services to use their NACAP data to identify where they need to improve and rally and lobby their colleagues in doctors’ surgeries and hospitals, their commissioners and national decision makers to recognise issues and make change. Reducing waiting times will be particularly challenging following the impact of COVID-19 and we as national organisations must work with and support PR services in doing this.

PR following COVID-19 and final thoughts

The way PR is delivered will undoubtedly have to change. Many PR services are already working to adapt their service in order to keep providing care. This must be applauded, particularly as the provision of remote PR was low in the 2019 clinical audit and many services are having to completely re-think the way that they work. NACAP will continue to support services by providing data to inform these changes and any improvements needed.

By using the PR audit data, we can provide services and national organisations like the Taskforce for Lung Health with the information they need to take action, plan improvement projects and lobby for change. We can also alert decision makers to the issues which have emerged (inequalities in access, waiting times), and help influence strategic change and improvement. NACAP provides PR services with real-time data which they can use to review their performance against key aspects of care on a daily basis, and monitor the progress of changes and improvements made.

We would like to remind PR services how important their data is in enabling NACAP to do this. We would not be able to do what we do without it and we therefore encourage services to keep the data coming. We will support them in any way that we can in doing this and continue to be grateful for their support and enthusiasm for being part of our work.

*These results present care of COPD patients assessed for PR between 1 June – 30 November 2019 and the organisation of services between July – September 2019. It is important to note that these results report on pre-COVID care and service organisation and are not able to give an indication of the impact of the pandemic on PR services or the care they have been able to provide during this time. 

You can read the latest NACAP audit here. The Taskforce for Lung Health recommends that access to PR is improved, so that every person with an MRC breathlessness score of grade 2 and above is identified, referred to and has the opportunity to complete a programme. Gathering data on PR helps us to identify the gaps in existing care, so that we can work to improve access to PR at a local and national level.


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23 February 2021