Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is one of the most effective treatments for people with lung conditions like COPD and can also be of benefit for pulmonary fibrosis and bronchiectasis. Yet, some people who would benefit aren't eligible for NHS treatment or can't access PR.

Improving access to PR could improve the health of people with lung disease and at the same time save the NHS money. Currently, not enough people who are eligible are being referred to PR.

We need PR to be available to everyone who would benefit from it. This means more services, more staff and more referrals for treatment.

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

The PR package includes a tailored physical activity programme, information about managing your condition, nutrition advice and psychological support.

Pulmonary rehabilitation (PR) is one of the most effective treatments for people with lung conditions like COPD. It includes a physical activity programme, tailored for each person, alongside information about managing your condition and symptoms, and what to do in the case of a flare up.

It is usually provided by a team of health care professionals such as 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. It helps people manage their condition and enjoy a better quality of life. There’s also evidence that it reduces levels of anxiety and depression and the risk of ending up in hospital.

 

Whilst this page focuses on people with COPD, people with other lung conditions such as pulmonary fibrosis and bronchiectasis can also benefit from PR. We will be releasing more information on PR for people with pulmonary fibrosis through the data tracker soon. Sign up at the bottom of the page to stay up to date with new releases. 

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 number of PR services, data on access to services, the effectiveness and quality of services delivered, and difference made to the lives of people with lung disease.

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 to improve 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, like completion rates for PR participants or waiting times post referral.

COVID-19

The data on this page was collected before the COVID-19 pandemic

The data on this page was collected before the COVID-19 pandemic and therefore shows a picture of what PR looked like before lockdown. Because of social distancing and shielding advice, face-to-face PR classes were postponed early in the pandemic. Some programmes were cancelled, and others switched to delivering classes online, for example by video conferencing or other means.

We need significant investment in PR services and workforce to meet demand

Services have started to resume, making adaptions for infection control, but face significant challenges. There is likely to be increased demand for PR, because of the backlog of care and the rehab needs of people who are recovering from COVID-19, some of whom are being referred to PR teams. We need significant investment in PR services and workforce in order to ensure that people with lung conditions and those recovering from COVID-19 have access to PR.

Accessing PR

PR services are beneficial for people living with a range of respiratory diseases

PR is useful for a range of respiratory diseases, which is why it is important that services are available for everyone who may benefit.  Currently, 100% of services accept people with COPD and 95% accept people with non-COPD respiratory diseases. COPD, however, is the most common respiratory disease for which PR is used as a treatment. On average, people with COPD make up 82% of attendees, with only 18% of attendees living with another respiratory disease.

To make full use of these services we need to ensure that health care professionals are actively offering PR as a treatment option to all those who would benefit, including people with pulmonary fibrosis and bronchiectasis.

Although the benefits of PR are widely recognised, many people who could benefit are not offered it

Many people with lung disease are not referred to PR because services might not be available where they live, programmes are full and have long waiting lists or because of strict eligibility criteria.

The most recent estimates show that only 15% of eligible people are referred for PR

Figures from the 2015 NACAP PR audit state that, out of an estimated 446,000 people who had COPD and were eligible for PR (those with an MRC grade of 3 -5), only 68,000 were referred in 2014. This means that at the time, just 15% of people who could benefit from PR were offered the treatment.

Unfortunately, due to poor data on the number of people currently living with COPD, the above figures have not been updated for the 2017 or 2020 audits. It is crucial that we understand what proportion of the COPD population is receiving PR so that we can effectively plan capacity and understand how much unmet need there is. 

The proportion of the eligible COPD population who received a PR referral (2014)

PR has been shown to be effective in those with less severe breathing difficulties, yet national guidance does not require referrals for this group

The Medical Research Council Dyspnoea Scale
MRC Grade Description
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying on the level or walking up a hill
3 Walks slower than most people on the level, stops after a mile or stops after 15 minutes walking at own pace
4 Stops for breath after walking about 100 yards or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when undressing

MRC grade is used to measure the severity of a person’s respiratory disease based on their degree of breathlessness related to certain activities. You can see a breakdown of this on the right. PR has been shown to be effective even in those with less severe breathing difficulties (MRC 2). Starting PR as early as possible means that the potential benefits of the treatment can be extended, as people with lung conditions are therefore less likely to deteriorate before starting treatment.

In light of this, the Taskforce’s recommendation is to actively identify and refer those with an MRC grade of 2. This goes beyond the current BTS quality standard which recommends referrals for those with an MRC grade of 3, but states that services should accept people with an MRC grade of 2, if they are referred.

Guidelines from the National Institute for Health and Care Excellence (NICE), state that referrals generally apply to those with an MRC grade of 3 or above, although they do state that it is dependent on the individual. 

What this means is that today, not many people who have an MRC grade of 2, are getting the benefit of PR. The Taskforce would like to see all those with an MRC grade of 2 and above actively identified and referred to PR. This will help ensure that the treatment can provide the maximum benefit to the quality of life of those need it.

Only 19% of PR attendees had an MRC grade of 2 despite making up 38% of the COPD population

The chart to the right offers a breakdown of PR attendees by MRC grade. Those with an MRC grade of 2 make up 38% of the COPD population, but only made up 19% of PR attendees in 2020. This is nearly half of what the number of attendees we could expect if all eligible people with an MRC grade of 2 were being referred. 

People with an MRC Grade of 1 are unlikely to be referred to PR, although do make up a small number of attendees. Those with an MRC grade of 3 make up the largest group of attendees (40%), while those with an MRC grade of 4 make up 33%. 9% of attendees have an MRC grade of 5.  Figures across all MRC grades are consistent between 2017 and 2020. By increasing referrals for people with an MRC grade of 2, PR services would better reflect the needs within the COPD population. 

MRC 1MRC 2MRC 3MRC 4MRC 5
COPD population0.180.380.260.140.03
National Average 20200.020.180.380.330.09
National Average 20170.020.170.400.330.08

Nearly a quarter of services in England did not accept people with an MRC grade of 2

Data from the 2017 NACAP audit showed that 24% of services in England did not accept people with an MRC grade of 2, and 15% had no MRC 2 referrals. This is despite the BTS quality improvement metric that all services should accept MRC 2 referrals if referred.

The Taskforce would like to see 100% of services accepting referrals for those with an MRC grade 2 and above. We need to see more referrals for this group.

Not enough people receive a referral after emergency care for an acute COPD exacerbation

People can receive a referral to PR in various ways and at different times. Most referrals for PR are to help manage stable COPD, but there should be more referrals offered after treatment for an acute exacerbation of COPD.

Different ways to be referred for PR

National Average 2020
Primary/Community services: AECOPD0.04
Primary/Community services: Stable COPD0.66
Secondary care services: AECOPD0.06
Secondary care services: Stable COPD0.22
Self-referral0.01

You can receive a referral to PR via the following:

  • Emergency primary care services (emergency GP appointment) after an acute exacerbation of COPD (AECOPD)
  • Primary care services,  including GP or community services to help manage stable COPD
  • Emergency secondary care (accident and emergency) after an acute exacerbation of COPD (AECOPD)
  • Routine secondary care, such as through a hospital, to help manage stable COPD
National Average 2020
Primary/Community services: AECOPD0.04
Primary/Community services: Stable COPD0.66
Secondary care services: AECOPD0.06
Secondary care services: Stable COPD0.22
Self-referral0.01

Most referrals for PR are to help manage stable COPD. The majority of these (66%), take place through primary care, likely through a GP, and 22% take place through secondary care, through a hospital or specialist centre.

However, every emergency visit to a hospital for an acute exacerbation of COPD (AECOPD), should result in a discharge bundle including assessment for, and referral to, pulmonary rehabilitation. Similarly, an acute exacerbation of COPD dealt with in primary care, such as through an emergency GP appointment, should also be followed up with a PR referral.

National Average 2020
Primary/Community services: AECOPD0.04
Primary/Community services: Stable COPD0.66
Secondary care services: AECOPD0.06
Secondary care services: Stable COPD0.22
Self-referral0.01

Despite this, the proportion of referrals through secondary care after treatment for COPD exacerbation is very low, at only 6%. This is up from 3% for all AECOPD referrals (primary and secondary) in the 2017 audit, which is positive, yet according to the RCP, these levels should still be higher.

The may suggest that people are not getting referrals from hospitals or are not going forward with the treatment, despite being referred. We can see from the NACAP COPD audit programme that only 56.0% of people treated for an acute exacerbation of COPD in hospital were assessed for suitability for pulmonary rehabilitation, despite an assessment being a standard component of a discharge bundle.

We are working with RCP to understand what a realistic target for this AECOPD referrals is.

Savings to the NHS

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

PR is a effective way to manage lung disease. The Chartered Society of Physiotherapy’s (CSP) COPD PRIME Tool looks at the costs and savings assosiated 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

NACAP monitors the quality of PR services across the country through the PR audit programme. The Taskforce would like to see PR provided at a consistently high standard to everyone who needs it. Nearly all people referred to PR should receive an initial assessment, be offered a place on a PR course, and go on to complete PR. 

Once enrolled, PR completion rates are high, but not enough people referred receive an initial assessment to access the course

The patient journey for PR

The patient pathway for PR is outlined to the right. This is what the process looks like after people are referred to PR. The process includes an inital assessment, enrollment onto a course, completion of a PR and the delivery of an individualised discharge plan upon completion.

Not all those referred complete the entire patient pathway. By reducing drop-offs in the patient pathway, we can ensure that the maximum number of people possible get onto and complete a PR programme. This will mean that people get the best possible outcomes from the treatment and that the resources are used as efficiently as possible. Right now, the main issue is with access to PR services.  

As discussed, not enough of the COPD population are referred for PR in the first place. However, even once referred, data from the 2017 PR audit shows that nearly a third don't go on to receive an initial assessment and so cannot start PR. This could be several reasons, including patient choice or clinical unsuitability. However, by ensuring appropriate referrals and good availability of initial assessments, this figure should improve.

On a positive note, once assessed, nearly everyone is enrolled onto a course and completion rates for PR are high. 

Waiting times to access PR are too long

Ensuring ready access to PR as and when people need it is important in helping people to avoid exacerbations. This is why waiting times need to be reduced. 

Targets for completion rates, discharge plans and waiting times for PR

Bar titleIcon filenameValueRange-minRange-maxTargetLeft is goodLine of peopleScale-minScale-maxUnitRange-min-labelRange-max-label
Proportion of those who are enrolled who complete PR7270%2020
Proportion of people receiving an individualised discharge plan74100%2020
Proportion of people with stable COPD starting PR within 90 days of a referral5785%2020
Proportion of patients with AECOPD starting PR within 30 days of a referral1585%2020

The number of people completing PR in England is high (72%). Completion rates exceed the national quality improvement target of 70% and have risen since 2017 (67%).

However, it has been shown that the benefits of PR can wear off over time. It is therefore essential that all those who complete PR receive an individualised discharge plan detailing how to maintain the benefits of the treatment for as long as possible. This discharge plan gives people the tools to maintain any exercise and lifestyle changes. Currently, 74% of people who complete PR receive an individualised discharge plan. This is down from 79% in 2017. The Taskforce would like to see 100% of people completing PR receiving an individualised discharge plan.

Bar titleIcon filenameValueRange-minRange-maxTargetLeft is goodLine of peopleScale-minScale-maxUnitRange-min-labelRange-max-label
Proportion of those who are enrolled who complete PR7270%2020
Proportion of people receiving an individualised discharge plan74100%2020
Proportion of people with stable COPD starting PR within 90 days of a referral5785%2020
Proportion of patients with AECOPD starting PR within 30 days of a referral1585%2020

The BTS quality standard states that people with stable COPD should start PR within 90 days of receipt of referral.

Data on services in England shows that only 57% of people with stable COPD started PR within the 90 day target. Longer waiting times for PR expose the individual to an unnecessary, increased risk of admission to hospital. It is essential that we ensure people start PR within the recommended time.

The BTS quality standard for waiting times after a referral following an acute exacerbation for COPD is 30 days. These referrals are more urgent as they are given to people with COPD who are in poor health.

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. 

A map of PR service data across England

Use the filters below to change the map - definitions for the filters will appear as you click them

Who uses PR services?

PR services have a near even split of male and female attendees

Across England, PR service attendees are on average 54% male and 46% female, with very small numbers of people identifying as transgender or ‘other’.

The average age of PR attendees ranges from 60 - 82 years across England

PR is available for anyone eligible as a result of their condition and incorporates people from a mix of ages. The average age of attendees at PR services across the country ranges from 60 - 82 years.  There will, however, be people using PR services that are both younger and older than this as these figures only represent the average age per service.

Average age of attendeesNo. of services with average age
602
614
620
634
649
6521
6620
6712
6885
6936
70110
7177
7286
7360
7440
752
7613
772
780
792
800
810
822

1 in 4 people using PR services are from the most deprived parts of society

The Index of Multiple Deprivation (IMD) is used to classify the relative deprivation of an area by assessing factors such as education, health, crime and employment.

Data on the IMD scores of PR attendees shows that the most deprived people are the most common users of PR services. 1 in 4 people using PR services have an IMD score in the lowest 20% (Q1), with the usage of PR services reducing gradually as deprivation improves. We know that respiratory diseases are more prevalent in deprived communities. 

It’s important that PR services acknowledge these inequalities and can support anyone who may benefit to access and complete PR. This might involve providing transport to those who need it to access PR classes.

YearQ1Q2Q3Q4Q5
20170.2530.2170.20.1770.153
20200.2590.2020.1980.1850.156

Our Asks

We need:

  • Better access to PR: This means more referrals, shorter waiting times, and more services across England. Services should be available for all those with an MRC grade of 2 and above. 
  • Consistent high-quality services: Services that meet the BTS quality standards and national quality improvement targets. 
  • Reliable AECOPD referrals: Referrals to be reliably offered after treatment for an acute exacerbation of COPD. 
  • Consistent high-quality data: Regular data on PR services through the National Asthma and COPD Audit Programme to monitor all of the above.

Help and more info

You can find more information on PR via the British Lung Foundation's website, along with information on digital PR in light of COVID-19.

Data sources

All data sources can be found on our data sources page