Improving access to pulmonary rehabilitation

NHS England has just published new guidance on developing the workforce to improve access to pulmonary rehab (PR)

Improving access to pulmonary rehabilitation

CSP policy head Rachel Newton explores the CSP’s role in shaping the new guidance and looks at new digital approaches to PR now being advocated by NICE.

Chronic respiratory conditions are one of the greatest causes of health inequality, with both low referral rates, particularly from primary care, and low take up and completion rates for pulmonary rehabilitation. 

Most people eligible for pulmonary rehabilitation are not being offered it and when they are offered it, they are often not prepared for it or told how important it is as part of treatment.

In addition, many people who would benefit from pulmonary rehabilitation are not eligible for it, because their condition hasn’t deteriorated sufficiently – even though rehabilitation can delay or prevent respiratory conditions from getting worse. 

Others do meet the current criteria but can’t take up pulmonary rehabilitation for a range of reasons. This could be because they work – 44 per cent of people with chronic obstructive pulmonary disease (COPD) are below retirement age. Others will face barriers to participation due to other health issues – for example, a third of patients with COPD will also have osteoporosis and depression.  

Seeking new ways to expand rehab provision 

The NHS England (NHSE) pulmonary rehabilitation programme seeks to deliver the promises to expand provision in the NHS Long Term Plan 2019. As part of this, in the last couple of weeks NHSE has published new guidance on how to expand and develop the workforce to deliver increased access required to meet population need.

In my role as the CSP’s head of policy, I chaired the working group of experts that produced the guidance. This included leading CSP members in respiratory practice. Chronic respiratory conditions are one of the biggest causes of health inequality, and poor access to rehab drives this.  

These needs can only be met with development of the workforce and increasing capacity, which means enabling the workforce to work in new ways – including incorporating digital provision to create hybrid services and working in an integrated way with rehab provision on other condition pathways.  

As well as physiotherapists and physio support workers, it also means developing and utilising the whole workforce including other registered clinicians, students, expert volunteers, advanced practitioners, exercise professionals and administrators. 

But we mustn’t shy away from the fact that it also means expanding pulmonary rehab workforce numbers overall. 

The CSP has been pleased to support the NHSE pulmonary rehabilitation programme to improve patient access, but in addressing the barriers to referral in the short term this may result in longer waiting lists as unmet need will be visible. This might be uncomfortable, but I believe it is unavoidable if PR service managers are to build the case to expand teams to provide the safe and effective staffing levels required. 

Potential of digital  

‘It is important that people who qualify for pulmonary rehab are first offered face to face PR,’ says Enya Daynes, chair of the British Thoracic Society pulmonary rehabilitation specialist advisory group and who contributed to the NICE early value assessment for digital technologies. ‘[But] for those who are unable to attend a twice-weekly supervised programme, digital tools offer an exciting innovation that can make PR more inclusive for people who would otherwise miss out’. 

Jane Stokes, physiotherapist, and head of customer success at my mhealth, adds, ‘myCOPD is a digital therapeutic app which has been shown to complement and enhance face to face pulmonary rehabilitation services. We don’t provide an alternative service, but rather we work in partnership with PR services to support a more flexible and accessible, hybrid, service delivery model. 

‘Using the app as part of a supported self-management approach, pulmonary rehabilitation teams can set goals with their patients, review progress, promote engagement and motivate the essential behaviour changes all via their clinical dashboard. 

‘The evidence shows that technologies like this can overcome some of the barriers to participation in pulmonary rehabilitation, critical to tackling health inequalities,‘ she added.  

Thinking differently about rehab

Emma Chaplin, physiotherapist and clinical lead for pulmonary and Covid rehabilitation at University Hospitals of Leicester NHS Trust, has led the roll-out of SPACE for COPD® in her service. 

SPACE for COPD® is an interactive web-based programme of exercise and education, designed to help individuals manage their condition more effectively and reduce the impact it has on their day-to-day life,’ says Emma. 

‘The self-management programme contains a range of educational topics to help an individual with COPD understand their condition better – such as advice on medication, breathing control, exercise, and nutrition. 

‘Individuals are also encouraged to set goals and progress through a prescribed exercise programme and achieve weekly targets.

‘The administration site allows trained health care professionals to monitor and track patients progress remotely and make contact with the patient through a messaging system,’ Emma goes on. 

‘The patient can also contact the local team of health care professionals through an “ask the expert” facility on the patient site.

‘During the Covid-19 pandemic, clinical services were forced to think differently about how they delivered pulmonary rehabilitation. SPACE for COPD® has provided a successful alternative that I believe is here to stay for all respiratory patients who will not be able to access rehabilitation otherwise or decline supervised face to face classes.’ 

Some of the next steps for SPACE for COPD® are to make it multilingual to be accessible to non-English speaking patients and exploring other applications that would expand the use of the interactive components of the digital programme. 

Also under active consideration is how to make it available for patients with other chronic respiratory diseases.

Taking a digital approach

In its newly published guidance, NICE recommends two digital offers, myCOPD and SPACE for COPD® as part of NHS pulmonary rehabilitation services, offering services the opportunity to begin integrating the hybrid approach described above into their rehab provision. 

The new British Thoracic Society PR clinical statement published in 2023 acknowledges that while existing evidence suggests face to face group pulmonary rehab programmes are the gold standard, offering digital provision is a valuable alternative to those who otherwise wouldn’t be able to access programmes. 

For many of people who currently can’t access pulmonary rehabilitation services, digital pulmonary rehab may be the solution. Others may have already completed a pulmonary rehabilitation programme but need further support with maintaining fitness levels.

More information

British Thoracic Society PR clinical statement: Quality Improvement Pulmonary Rehabilitation.
New NICE guidance on COPD: Digital technologies to deliver pulmonary rehabilitation programmes for adults with COPD: early value assessment.

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