Pulmonary rehabilitation for people with Chronic Obstructive Pulmonary Disease (COPD)

What this page tells you

This page provides evidence and information relating to pulmonary rehabilitation treatment for people living with COPD. It checks progress against the Taskforce recommendation to:

Improve access to pulmonary rehabilitation so that every person with an MRC breathlessness score of grades 2 and above is identified, referred to, and has the opportunity to complete, a programme

This will be measured through the following measures of success:

Increased referral to, and completion rates for, pulmonary rehabilitation programmes for people with COPD with an MRC breathlessness score of grade 2 and above.

What is pulmonary rehabilitation (PR)?

PR is a tailored physical activity programme to help treat lung disease

Pulmonary rehabilitation (PR) is one of the most effective treatments for people with lung conditions like COPD. It includes a tailored package of care covering physical activity, information on managing your condition - including what to do in the case of a flare-up - and nutrition and lifestyle advice. 

It is usually provided by a team of health care professionals including physiotherapists and occupational therapists. A PR course is run in groups of around 8-16 people and lasts around six to eight weeks.

PR is proven to help improve exercise capacity and reduce breathlessness. People who complete PR can walk further and feel less breathless doing day-to-day activities. PR helps people manage their condition, experience fewer symptoms, and enjoy a better quality of life. There’s also evidence that it reduces levels of anxiety and depression and reduces the likelihood of ending up in hospital.

 

What is the Taskforce calling for?

A comment on data

Data from the National Asthma and COPD Audit Programme (NACAP) was used to build this page

The National Asthma and COPD Audit Programme (NACAP) has run several audits of PR services in England and Wales since 2015. These capture the availability of and access to services, the effectiveness and quality of services, and the difference made to the lives of people with lung disease. The most recent audit data used throughout this page are from November 2019, the prior audit datasets also used are from May 2019, 2017, and 2015.  

The Taskforce has worked with the Royal College of Physicians (RCP), who manage the NACAP audits, to present the audit data in a meaningful way throughout this page. The purpose of this is to provide information for people with lung disease and make the case for policy changes, mainly focussed on improving access to PR.

This page also references the British Thoracic Society's Quality Standards for Pulmonary Rehabilitation in Adults. These are used throughout the NACAP PR audit reports to inform national quality improvement targets for PR services. These include targets for completion rates, the delivery of post-PR exercise plans, and waiting times.

COVID-19 and funding

Accessing PR

The importance of PR in early stage lung disease

PR has been shown to be effective in those with less severe breathing difficulties, yet national referral guidance neglects this

MRC grade is used to measure the severity of a person’s respiratory symptoms based on their breathlessness in relation to activity. You can see a breakdown of the grades to the right. PR has been shown to be effective even in those with less severe breathing difficulties (MRC grade 2). However, the current BTS quality standards only recommend referrals for those with an MRC grade of 3 and above and referral data from the QOF only captures those with an MRC grade of 3 and above. 

Failing to focus on those with an MRC grade of 2 also means often a person's symptoms will have worsened before they receive a referral to PR. By starting PR as early as possible, PR can help people hold on to their quality of life.

The Taskforce would like to see both of the current guidelines changed to ensure services are available for people with an MRC grade of 2 are this group is actively identified and referred. Currently, referrals for this group are low and not all services accept people with an MRC grade of 2.

Referral pathways

Savings to the NHS

Delivering PR to all those who need it would reduce the impact of COPD on the NHS

PR is an effective way to manage lung disease. The Chartered Society of Physiotherapy’s (CSP) COPD PRIME Tool looks at the costs and savings associated with PR and provides estimates based on if PR was delivered to all people currently eligible (MRC grade 3 and above).

Based on analysis using this tool, improving access to PR could reduce exacerbations in the eligible population by 13%.  This would free up 150,924 GP appointments, 106,532 hospital bed days and 26,634 hospital admissions, all of which currently costs the NHS £69m per year.

PR has the ability to improve the lives of people with lung disease and reduce the impact on the NHS. The potential savings from PR are dependent on a number of factors, including completion rates. The higher completion rates are, the greater the benefit to people with lung disease and to the NHS. PR is also likely to free up social care services as people would need less support, however, this is not evaluated within the tool. 

Quality of PR services

Low referral rates present significant challenges, but even once referred not enough people are assessed for enrolment and waiting times are too long

The patient pathway for PR is outlined to the right. The process includes a referral, an initial assessment, enrolment onto a course, completion of a course, and the delivery of an individualized discharge plan upon discharge. Ensuring people can access and complete a PR course in a full and timely manner, ensures the maximum benefit to the individual and the efficient use of NHS resources. 

Right now, low referral rates present a significant challenge to accessing PR, but even once referred, not enough people are given an initial assessment. Without an initial assessment, you cannot start PR. These people may be unable to access an assessment for many reasons; services may not have space; individuals may be unable to access the assessment due to ill-health, transport issues or trouble getting there safely; they may choose not to attend, or they may simply be left waiting too long. On average services are falling considerably short on waiting time targets - more on this in the slides below.

Between 1 July and 30 September 2019 out of a sample of services who submitted referral and assessment numbers, services received 31,106 referrals but only delivered 16,793 initial assessments. This suggests a considerable gap in service capacity with only 53% of referrals progressing to an initial assessment within that audit period. By improving waiting times and reducing drop-offs in the patient pathway, we can ensure more people benefit from PR as and when they need it.

Many of the Taskforce, NACAP and BTS quality improvement targets are not being met

Completion rates, the delivery of discharge plans upon completion of PR, and waiting times for people with both stable and exacerbated COPD are all areas where on average services are falling short of target levels. These are targets either outlined in the NACAP report as national quality improvement priorities, supported by the BTS quality standards, or targets recommended by the Taskforce. You can see how current levels compare against these targets below.

See how your area is performing

Use the map below to find PR services near you and to explore how services across the country are performing. Understanding why some services or some areas of the country perform better than others can help improve services. 

Who uses PR services?

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Data sources