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First Pulmonary Rehabilitation audit shows variation in care nationally

The National Chronic Obstructive Pulmonary Disease (COPD) Programme for the first time today, reviews the resources and the organisation of Pulmonary Rehabilitation services in both England and Wales, which are set against British Thoracic Society (BTS) quality standards.

The report entitled: ‘Pulmonary Rehabilitation: Time to breathe better’, shows that most pulmonary rehabilitation (PR) programmes are providing treatment in line with national guidelines and quality standards. However, there are some variations of care, and not all eligible patients who would benefit from PR treatment are being referred, and a significant number of those who are referred do not attend for treatment.

Key areas for improvement include:
  • Compared to the estimated need, insufficient numbers of patients with COPD are being referred for PR. Of those who are referred for PR, 31% do not attend their appointment for an assessment.
  • Referral for PR following hospitalisation for COPD is known to benefit patients but only 68% of programmes offer this, and only 22% of programmes are able to provide it within 1 month of discharge from hospital (as set out in the quality standards).
  • A number of programmes report insecurity of ongoing funding and of those with fixed term funding, 79% reported that this was for 2 years or less.
  • In some programmes (18%), the prescription of exercise during PR is not performed in line with evidence based guidance and some programmes (35%) do not provide a personal on-going exercise plan for patients when they complete PR.
Main recommendations for PR commissioners and providers include:
  • Commissioners and providers should work together to review and enhance referral pathways for PR and education and training to ensure that all eligible patients in their area are offered treatment.
  • Commissioners should take steps to ensure PR providers have an adequate long term funding framework that will allow programmes to recruit and retain staff with an appropriate skill.
  • PR programmes should review their exercise prescription practice to ensure that they are providing treatment in line with BTS Quality standards.
  • PR programmes should examine their discharge processes to ensure each patient receives a written, individualised plan for ongoing exercise and maintenance when they finish rehabilitation.

Patients can now begin to use these results to understand the quality of their local services and if these services do not meet the standards, both patients and commissioners should encourage providers to improve their standards. The full report can be found at the National COPD Audit Programme.

The second report, expected early next year, will look at what happens to individual patients in more detail.

The review identified 230 PR programmes across England and Wales. Participation in the COPD audit has been excellent, with 97% providing data in England and a 100% response rate in Wales which is really encouraging.

Prof Michael Steiner, national COPD audit clinical lead for pulmonary rehabilitation and consultant respiratory physician, said:

This is the first national audit of resources and organisation of pulmonary rehabilitation (PR) services. It is the first step to understanding the current availability and quality of PR services across England and Wales. We have been really encouraged by the overwhelming participation of PR providers and hope the results will be a starting point to improving care for people with COPD.

Bernard Higgins, Chair of the British Thoracic Society said:

The audit is an important milestone and has examined Pulmonary Rehabilitation services across England and Wales for the first time ever. It has assessed the services provided against the BTS Quality Standards for Pulmonary Rehabilitation and we are pleased to note that there is an overall adherence to these standards. However, variation in the quality of care remains across programmes and this audit will provide the impetus for a widespread improvement in this important area.

COPD is the collective term for emphysema and chronic bronchitis, and is mainly caused by smoking. People with COPD have breathing difficulties, which can affect the quality of their everyday life and prevents normal physical activity. Pulmonary Rehabilitation (PR) is a combination of exercises to improve physical activity and fitness, together with advice and education about self-care; all of which help patients with COPD to cope with this incurable medical condition. Exercise programmes include a mixture of strength and aerobic exercise training. PR has been proven to reduce breathlessness and help those who live with COPD undertake every day activities like walking or climbing stairs.

PR is an accepted standard of care for people with COPD and its lack of availability or referral can affect the quality of care for patients. PR is one of the few therapies that has shown to reduce time spent in hospital and is a really good cost effective treatment for COPD. Therefore, PR programmes should be a high priority for national and local health policymakers.

The National COPD Audit Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP)*. The National COPD Audit Programme is led by the Royal College of Physicians, working closely with stakeholders, including the British Thoracic Society (BTS), the Primary Care Respiratory Society UK (PCRS-UK), the British Lung Foundation (BLF) and the Royal College of General Practitioners (RCGP).

Notes to editors

  • For more information or to arrange an interview, please contact Joanna Morgan, communications manager, RCP Care Quality Improvement Department on +44 (0) 20 3075 1354.
  • Chronic Obstructive Pulmonary Disease (COPD) is a common and usually progressive disease and is a leading cause of mortality and morbidity globally: the World Health Organisation estimates that COPD is responsible for 5% of annual deaths globally (World Health Organisation). It causes progressive breathlessness with cough and wheeze, punctuated by exacerbations (flare-ups) that may lead to hospital admission. Whilst 835,000 people in England have been diagnosed with the disease, a further 2 million people with COPD may be unidentified (Department of Health, 2010). COPD is the 5th biggest killer in the UK and the only major cause of death on the increase. Respiratory disease is the third leading cause of death in England, with approximately 23,000 people dying from COPD each year[1]. More than six million people in England suffer with COPD or asthma. Respiratory disease is one of the principal reasons for emergency admission to hospital.
  • The National COPD Audit Programme brings together primary care, secondary care, pulmonary rehabilitation and patient experience. This national audit programme comprises comprehensive multidisciplinary, collaborative working and aims to drive improvements in the quality of care and services provided for COPD patients in England and Wales. It is led by the RCP, working closely with a range of key stakeholders, including the British Thoracic Society (BTS), the Primary Care Respiratory Society (PCRS-UK), the British Lung Foundation (BLF) and the Royal College of General Practitioners (RCGP).

The Royal College of Physicians

The Royal College of Physicians (RCP) plays a leading role in the delivery of high‐quality patient care by setting standards of medical practice and promoting clinical excellence. The RCP provides physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing 30,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare. The Clinical Effectiveness and Evaluation Unit (CEEU) of the RCP runs projects that aim to improve healthcare in line with the best evidence for clinical practice: national comparative clinical audits, the measurement of clinical and patient outcomes, clinical change management and guideline development.

The British Thoracic Society

The British Thoracic Society (BTS) was formed in 1982 by the amalgamation of the British Thoracic and Tuberculosis Association and the Thoracic Society, but their roots go back as far as the 1920s. BTS is a registered charity and a company limited by guarantee. The Society’s statutory objectives are: ‘the relief of sickness and the preservation and protection of public health by promoting the best standards of care for patients with respiratory and associated disorders, advancing knowledge about their causes, prevention and treatment and promoting the prevention of respiratory disorders’. Members include doctors, nurses, respiratory physiotherapists, scientists and other professionals with an interest in respiratory disease. In August 2015 BTS had 2,994 members. All members join because they share an interest in BTS’s main charitable objective, which is to improve the care of people with respiratory disorders.

*About HQIP, the National Clinical Audit Programme and how it is funded

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme (NCA), comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands. www.hqip.org.uk


[1] NHS Atlas of Variation in Healthcare for People with Respiratory Disease (September 2012)