Breathing new life into COPD care

Pulmonary rehabilitation is the cornerstone of effective treatment for Chronic Obstructive Pulmonary Disease (COPD), yet a shockingly low number of patients ever get to benefit. 

In 2016 a national clinical audit report revealed that while 40% of patients with COPD should be receiving pulmonary rehabilitation (PR) under National Institute for Health and Care Excellence (NICE) guidance, just 4 out of 10 of those eligible patients are even referred.  

What makes the data particularly startling is the strength of the evidence supporting the use of PR in improving outcomes and reducing the burden on services. Evidence suggests that PR reduces COPD exacerbations by 36% (see Physio Works 2017) which means if every eligible person was referred for PR, exacerbations could fall by a third.  

In turn, this would reduce COPD hospital admissions by 13%, halve the length of time spent in hospital for those admitted – saving 106,000 hospital days – reduce social care costs, and free up GP appointments.

In fact, so strong is the evidence that PR works, that the prestigious Cochrane Collaboration has taken the unusual step of ceasing further systematic reviews comparing its use to usual care. 

Yet cuts in rehabilitation services and chronic underinvestment has led to what Rachel Newton, the CSP’s Head of Policy, describes as an inconsistent and patchy service, with access determined not by need but geography. 

It is, she says, a classic tale of short-termism, one that she hopes may yet have a happy ending due to the efforts of respiratory experts from across 30 different organisations, including the CSP, who have published a five-year plan on lung health. 

Strategy vacuum

The Taskforce for Lung Health was first proposed in spring 2017 by the British Lung Foundation. 

‘There was a Cancer Strategy but no equivalent for lung health. That’s what the BLF are trying to do in convening the Taskforce. It’s a means of galvanising stakeholders to do something about the situation,’ says Ms Newton. 

In December 2018, the Taskforce, which includes the CSP and the Association for Chartered Physiotherapists in Respiratory Care, launched its five-year plan at the British Thoracic Society’s Winter Conference. It sets out a raft of measures with the aim of ‘creating a society where everyone can live with healthy lungs for as long as possible and have the best chance of living well, or recovering, when lung disease develops’.

The plan outlines ways to create clear pathways for timely, accurate and complete diagnosis for individuals with breathlessness and other respiratory symptoms.

Significantly, it includes the recommendation to improve access to pulmonary rehabilitation so that every eligible person is identified and given access to support, and that guidance on eligibility is widened.

It’s a laudable aim but one that can only come to fruition if backed with investment in staff and services.

Rachel Newton explains: ‘If, tomorrow, everyone who even the existing NICE guidance says should be referred was referred, they’d find the services don’t exist or there are long waits, because they are not funded and staffed sufficiently.

‘There’s a common theme with long-term conditions that patients don’t get the rehab they need after they leave hospital. It feels like an easier cut to make, but it’s really short-sighted. It just pushes more people into becoming emergency admissions and creates unnecessary levels of disability – which drives up social care needs. The evidence is absolutely clear for PR. From a commissioner or budget holder’s point of view it’s a no-brainer, because it reduces demand elsewhere in the system.’

Ambition gap 

NHS managers, with an eye on bed efficiencies and savings, agree. Danny Mortimer, chief executive of NHS Employers, which represents senior management says: ‘This report indicates the risk we face in the gap between our ambitions for our services and the people available to support their delivery.’

The five-year plan states that in order to meet current demand for PR, around 1,000 additional respiratory staff are needed. This includes 600 physiotherapists and other registered staff, and 400 support staff. This is ambitious but achievable. Since 2015/16 there has been an increase in student places of 41.5% in England (34% increase across the UK).

‘The growth in numbers of physio graduates coming out of the education system is a good news story, particularly when we consider nursing and doctor shortages. Now we need to turn this growth in supply into new posts and additional staffing,’ says Ms Newton. 

Investment in rehab services also makes moral sense, explains Ms Newton. ‘We know that COPD particularly affects older people. If you have to go into hospital it impacts on your health, making you less mobile, you become more at risk of other health conditions including depression. An exacerbation is frightening as well as debilitating. It’s essential to make sure that everyone with COPD who could benefit from PR gets referred.’

Commenting on the report’s findings, a spokesperson for the Department of Health and Social Care said the NHS Long Term Plan would ‘ensure staff have the support they need to deliver excellent care.’

Good practice

Ian Culligan, Chair of the Association for Chartered Physiotherapists in Respiratory Care (ACPRC) and member of the Taskforce, points out that pulmonary rehab transforms lives for patients. ‘Ensuring all patients can access the rehab they need will require a sustained increase in the capacity of services. This means more staff and translating the welcome growth in physio student numbers in the UK into posts in community-based rehab services.’ 

But he added that we also need to look at how rehab services are organised. ‘With increasing numbers of people living with multiple long term conditions, it no longer makes sense to organise much rehab care around single conditions. Instead services should be organised around patient symptoms and rehab needs relating to their whole health. We need to look at how best to utilise the value of support workers in running exercise classes and one-to-one support. We also need to use digital technology to support patients to manage their condition and improve adherence to exercise programmes. The physiotherapy profession has an important role to play in leading this change. ‘

The Taskforce calls on commissioners to ensure patients eligible for PR under NICE guidance get referred, and for the threshold to be lowered to include more people that evidence shows would benefit from PR. 

Rachel Newton would also like to see good practice replicated. In Grimsby, the social enterprise Care Plus runs ‘Hope’, a community-based service for COPD patients and older people at risk of falls. This initiative took two hospital-based rehabilitation services to create one community service. The multi-disciplinary team includes six physiotherapists and 80 volunteers – all former patients and carers - who act as motivators, role models and community educators – for example, giving talks to local residents’ groups. Lead respiratory physio Pamela Hancock says Hope uses a ‘medical model in a social context’: ‘We design and deliver services with the patient and their experience at its core’. The scheme has reduced numbers of hospital admissions, hip fractures, depression and anxiety, increased smoking cessation, and improved patients’ confidence and ability to undertake daily activity. 

Meanwhile early evaluation of Leicester NHS Trust’s ‘breathlessness rehab programme’ –  which offers aerobic exercise and strength circuit sessions, coupled with support for self-management – indicates patients are receiving quicker diagnoses, with reduced demand for follow-up visits.

The success of these schemes, together with the report’s findings, demonstrates how investing in pulmonary rehabilitation can reduce both long-term costs, and human suffering –  a win, win formula.