Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is one of the most effective treatments for people with COPD and can greatly benefit people other lung conditions like pulmonary fibrosis and bronchiectasis. Yet, access to PR is poor. The eligibility criteria are too strict, referral rates are low and waiting times are too long.

We need PR to be available to everyone who would benefit from it. This means more services, more staff and more referrals. This would improve the health of people living with lung disease and reduce the impact of lung disease on the NHS

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

PR package: Tailored physical activity, information on 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 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.

 

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. 

What is the Taskforce calling for?

Here is a summary of our main asks. Explore the page to find out what all this means and why we are calling for it. We need:

  • Better access to PR: This means more referrals, more assessments, 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 British Thoracic Society's quality standards and national quality improvement targets
  • Reliable emergency referrals: Referrals to be reliably offered to everyone 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.

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

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 or paused but many services have now resumed, having made adaptions for infection control, or by offering some classes online. This is good news but there is no national standard for virtual PR and services still face significant challenges regarding service delivery, funding, and capacity. 

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

COVID-19 has exacerbated existing capacity issues in rehab access. There is now an increased demand for PR due to both the backlog of care as well as the rehabilitation needs of people who are recovering from COVID-19, some of whom are now being referred to PR teams. This means that, now, more than ever, there is a need for additional capacity to deliver PR to those who need it. We need significant investment in PR services and workforce in order to ensure that services are available to meet this demand, supporting both people with existing lung conditions and those recovering from COVID-19.

Pre-pandemic only 78% of services had secured (permanent) funding. The remaining 22% of services had unsecured (temporary/fixed-term) funding. The average funding window for services with unsecured, fixed-term funding was just 2 years.

Accessing PR

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

People with lung disease may not be able to access PR services for several reasons such as: a lack of local availability; long waiting lists for existing services; strict eligibility criteria; or because their healthcare professional did not inform them about the service.

Only 43% of the eligible COPD population received a referral for PR in 2019

Figures from the Quality and Outcomes Framework (QOF) state that 43% of the eligible COPD population received a referral for PR in the preceding 12 months for 2019/20 data. This suggests a major improvement on the previous estimate of 15% in the 2015 NACAP audit. However, these figures were recorded using different data capture mechanisms and so may not be comparable.

Whether this is suggestive of a genuine improvement or not current rates are still too low. Well over half the eligible COPD (67%) still did not receive a referral. This is an estimated 200,000 plus eligible people without the care they need. 

An estimated 200,000 eligible people did not receive a referral in 2019

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

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 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.

Over 1 in 10 services still do not accept people with an MRC Grade of 2

Even though the BTS quality standard neglects to include a call for referrals for those with an MRC grade of 2. They do state that if referred those with an MRC grade of 2 should be accepted. However, the most recent audit data (November 2020) shows that over 1 in 10 services (11%) still do not accept people with an MRC Grade of 2.  This is up from 2017 where 26% of services did not accept referrals for people with an MRC grade of 2, but still leaves a considerable number of services unavailable for those who need them. 

If you haven't been referred early on and your symptoms are more severe, not to worry, PR is very effective. For the most recent audit, of patients who completed a discharge assessment (UK figures):

  • 40% of people reported an improved MRC grade upon completion
  • Nearly three-quarters of people (71%) achieved improvements in exercise capacity measured by a 6-minute walk test (6MWT) and 60% achieved improvements when measured by an Incremental Shuttle Walk Test (ISWT) 
  • Over half of attendees (56%) achieved improvements in health status based on the COPD Assessment Test (CAT)
  • 3 out of every 5 attendees (59%) achieved improvements in breathlessness based on the Chronic Respiratory Disease Questionnaire (CRQ).

These improvements show the impact PR can have on helping improve the quality of life of people with lung disease. The rates given above are based on individuals where scores were reported in full. 

Referral pathways

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. PR is a key treatment for managing stable COPD, and stable COPD referrals make up the bulk of referrals. However, every emergency visit to a hospital for an acute exacerbation of COPD should result in a discharge bundle that includes a referral to pulmonary rehabilitation, but investigations have shown this is not being implemented often enough. According to the RCP, current levels for referrals after an acute exacerbation of COPD in secondary care (AECOPD) are much lower than expected.

Different ways to be referred for PR

National Average: Nov 2020
PC: AECOPD0.03
PC: Stable COPD0.68
SC: AECOPD0.05
SC: Stable COPD0.23
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: Nov 2020
PC: AECOPD0.03
PC: Stable COPD0.68
SC: AECOPD0.05
SC: Stable COPD0.23
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.

The proportion of referrals for AECOPD is very low, at only 5%. This is up from 3% for all AECOPD referrals (primary and secondary) in the 2017 audit, which is positive, yet these levels should still be higher.

National Average: Nov 2020
PC: AECOPD0.03
PC: Stable COPD0.68
SC: AECOPD0.05
SC: Stable COPD0.23
Self-referral0.01

Low levels of secondary care, AECOPD referrals may suggest that people are not getting referrals from hospitals or are not going forward with the treatment, despite being referred, and thus data for these individuals may not be being captured. However, we can see from the NACAP COPD audit programme that only 56% 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 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

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. 

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 journey for PR

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.

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 PR66.470%Nov 2020
Proportion of people receiving an individualised discharge plan81.7100%Nov 2020
Proportion of patients with stable COPD starting PR within 90 days of a referral54.885%Nov 2020
Proportion of patients with AECOPD starting PR within 30 days of a referral13.185%Nov 2020

The national completion rate for PR in England for people with COPD was 68% for the most recent audit period. This falls just short of the national quality improvement target of 70%. Rates from the previous audits were 72% (May 2019) and 67% (2017). This suggests completion rates have not changed much in the last few years and while national completion rates have generally been near target levels, this is an average, and completion rates go as low as 22% in some services. See more on how rates vary across the country in the map below. The Taskforce would like to see completion rates in excess of 70% across all services. 

Ensuring people complete PR is essential in ensuring they receive the full benefit of PR, but so are discharge plans, more on this on the next slide. 

Bar titleIcon filenameValueRange-minRange-maxTargetLeft is goodLine of peopleScale-minScale-maxUnitRange-min-labelRange-max-label
Proportion of those who are enrolled who complete PR66.470%Nov 2020
Proportion of people receiving an individualised discharge plan81.7100%Nov 2020
Proportion of patients with stable COPD starting PR within 90 days of a referral54.885%Nov 2020
Proportion of patients with AECOPD starting PR within 30 days of a referral13.185%Nov 2020

It has been shown that the benefits of PR can wear off over time if exercise and lifestyle changes are not maintained. 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.

The most recent audit found that 82% of people who complete PR receive an individualised discharge plan. This is up from 80% for the previous 2019 audit period and 79% in 2017. The Taskforce would like to see 100% of people completing PR receiving an individualised discharge plan. 44% of services delivered discharge plans to 100% of their completers, while 13% delivered no discharge plans at all.

Bar titleIcon filenameValueRange-minRange-maxTargetLeft is goodLine of peopleScale-minScale-maxUnitRange-min-labelRange-max-label
Proportion of those who are enrolled who complete PR66.470%Nov 2020
Proportion of people receiving an individualised discharge plan81.7100%Nov 2020
Proportion of patients with stable COPD starting PR within 90 days of a referral54.885%Nov 2020
Proportion of patients with AECOPD starting PR within 30 days of a referral13.185%Nov 2020

The BTS quality standard states that people with stable COPD should start PR within 90 days of receipt of referral with a national quality improvement target of 85%. 

Data on services in England showed that only 55% of people with stable COPD started PR within the 90-day target. This is down from 59% in May 2019 and 62% in 2017. This shows that the proportion of people waiting in excess of 90 days has gotten worse. Longer waiting times for PR post an unnecessary, increased risk of exacerbations and hospital admission to the individual. It is essential that we ensure people start PR within the recommended time.

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 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. There is no national quality improvement target for this group although the Taskforce believes that levels should at least be in line with the 90-day target if not higher given the increased urgency of the patient group. However, the proportion of people referred to PR after an exacerbation of COPD is very low at just 13%, down from 15% in the previous 2019 audit. This means a significant proportion of people are waiting in excess of 30 days after an exacerbation of COPD putting an already vulnerable group at increased risk.  

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 62 - 80 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
621
641
652
662
678
6812
6921
7029
7126
7237
7314
7413
757
763
802

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. We know that respiratory diseases are more prevalent in deprived communities. 

Data on the IMD scores of PR attendees shows that people from the most deprived socioeconomic backgrounds 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.

It’s important that PR services acknowledge these inequalities so they can ensure anyone who may benefit from PR can access and complete it. For example, this might involve providing free transport to access PR for those who need it or review materials to make sure they are appropriate for everyone.

YearQ1Q2Q3Q4Q5
National Average: 20170.250.220.20.180.15
National Average: 2019 (May)0.2580.1980.1980.1880.158
National Average: 2019 (Nov)0.2520.2220.1920.1820.152

Our Asks

As outlined in the starting summary, we need:

  • Better access to PR: This means more referrals, more assessments, 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 British Thoracic Society's quality standards and national quality improvement targets
  • Reliable emergency referrals: Referrals to be reliably offered to everyone 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