Following last month's announcement of NHS England's Long Term Plan (LTP), the RCP engaged in an ongoing series of discussions covering the plan's most important themes. Here, Professor Mike Roberts highlights the role of pulmonary rehabilitation in the LTP.
The Long Term What?
The NHS Long Term Plan (remember that?) devotes over two pages to respiratory medicine recognising the importance of respiratory disease as a cause of high morbidity and death whilst it almost single handedly accounts for the annual winter pressures we all have to manage. So why, given the breadth of respiratory disease, is over a quarter of this section focussed on pulmonary rehabilitation (PR) as a key intervention in preventing admission and improving patient outcomes for those with respiratory long term conditions?
Hurrah for PR
The answer is simple: both patients and health care professionals understand that pulmonary rehabilitation (PR) is one of the most clinically and cost effective interventions we can make and yet is one of the most under-utilised in the health care profession.
[...] pulmonary rehabilitation is one of the most clinically and cost effective interventions we can make and yet is one of the most under-utilised in the health care profession.
The recently published British Lung Foundation Taskforce report promotes rehabilitation as the most patient supported management option available whilst the Cochrane review states ‘PR significantly improves exercise capacity, relieves dyspnoea and fatigue, improves emotional function and the sense of control that individuals have over their condition’ with additional randomised control trial (RCT) data demonstrating benefits in reduced hospital admissions. With a quality-adjusted life year (QALY) of around £2-8k compared to inhaled drugs of between £7-187k per QALY.
Is it a no-brainer?
So its sounds like a no-brainer but all is not quite as simple as that. The LTP also quotes very low PR referral rates from both primary care in stable patients, and from secondary care post discharge, both of which are points where benefits have been demonstrated in trials.
In addition, we have demonstrated in the RCP’s managed national PR audit that about a third of patients referred fail to register and completion rates from patients who do attend are around only 60%. Although these completers achieve improvements similar to those observed in the RCTs and are significantly less likely to be admitted to hospital within 6 months compared to non-completers.
So why the challenge?
So why is this so challenging? There are a number of reasons why I believe this isn’t working as well as it should be. Referrals are low because clinicians are not always aware of PR or its benefits or who should be referred. Often they don’t know what PR actually is so explaining it to a patient is a non-starter. If you don’t know yourself ask your local PR provider to observe a session or if that’s not possible there are lots of great samples on YouTube.
Referrals are low because clinicians are not always aware of PR or its benefits or who should be referred
Patients sometimes feel too unwell to attend particularly at time of discharge so approaching them again later is a better option for some, or providing a home or distance learning package or digital alternative. Distances to travel and convenience eg more than one change of bus makes attendance unlikely, timing of sessions for those working and time waiting to be assessed are all factors that disincentivise patients from attending. Respiratory exacerbations, mental health issues and poor staff engagement may all influence non-completion.
Let's stick to basics
So where does that leave us? The premise that PR is good for breathless or deconditioned people with Chronic Obstructive Pulmonary Disease (COPD), bronchiectasis and some with Interstitial lung disease remains good. Urging us to refer more patients is a good start but only part of the solution.
We need also to ensure that programmes are located in places that are convenient to travel to at times people can attend whilst exploring alternative delivery mechanisms that would be attractive, and of course equally as effective to the individual disabled by their chronic respiratory disease. We must learn to support patients through a course of 6 to 8 weeks to engage and motivate and of course all this requires more trained staff so that our enthusiasm does more than build a waiting list!
But make no mistake that this is an opportunity for us to work with our patients to co-design a new set of PR programmes that meet their needs, improve their health and wellbeing whilst reducing pressures on the NHS and its staff. Sounds like a win, win, situation.
Professor Mike Roberts is the senior clinical lead for NACAP.