Introduction

The NHS Long Term Plan recognised pulmonary rehabilitation as a high value intervention that can reduce days spent in hospital and improve outcomes for people living with chronic respiratory conditions [1, 2]. It identified the need to expand provision so that more people can benefit from this intervention.

However, Quality and Outcomes Framework (QOF) data for 2021/22 shows only 36.9% of the eligible population is being referred for pulmonary rehabilitation, and systems frequently report insufficient workforce capacity is hindering pulmonary rehabilitation and wider respiratory healthcare service expansion. Addressing this is key to reducing the gap in healthy life expectancy between communities.

This guidance – for systems (as commissioners of pulmonary rehabilitation services and accountable for workforce planning) and providers of pulmonary rehabilitation services – sets out the considerations when planning workforce expansion and development to address the shortfall in capacity:

• the safe and effective staffing level needed (in line with guidance in Pulmonary Rehabilitation Services Accreditation Scheme standards) to expand pulmonary rehabilitation capacity as referrals increase, without lengthening waiting times
• the core competencies and skill mix required to deliver a safe, effective and inclusive programme in accordance with clinical guidance
• the competencies and skill mix required to provide pulmonary rehabilitation to an increasingly complex population
• the competencies and skill mix required to develop new ways of working that are more accessible and support efficiency and effectiveness in the pathway

The guidance should be read in conjunction with Pulmonary Rehabilitation Programme outputs (workforce) 2023, on the FutureNHS Collaboration Platform. These other outputs from the NHS England programme include some innovations from around the country in the deployment of workforce, personalising care and growing teams: for example, by involving students on placement, apprenticeships and volunteers.

Why we need to develop as well as grow the workforce

Population needs are becoming better understood and changing over time.  The following considerations illustrate the need for multidisciplinary teams (MDTs) to have the skill set and capacity to meet the needs of people with co-morbidities and complex needs, and to design services to be accessible to all communities, to address health inequality:

• most (92%) of people with chronic obstructive pulmonary disease (COPD) have at least one other condition [3], and the co-morbidity profile is similar for other chronic lung disease cohorts, such as bronchiectasis and interstitial lung disease
• people with COPD have a 124% higher risk of coronary heart disease than non-COPD patients [4],and over a third also have osteoporosis and depression [5]
• currently half of all adults aged 65+ have two or more long-term conditions; this is expected to rise to two-thirds by 2035 [6]. Chronic respiratory conditions are common among these long-term conditions
• 44% of the population with COPD are below retirement age, and around one-quarter are not in work due to their COPD [7]
• people from the poorest 10% of households are over 2½ times more likely to have COPD than those from the most affluent 10% [8]. They are also less likely to be referred for pulmonary rehabilitation, and while those in the poorest 10% who are referred are less likely to complete the programme, their outcomes are just as good as for other groups when they do [9, 10]
• cohorts of patients other than those with COPD would also benefit from pulmonary rehabilitation, including those with bronchiectasis, interstitial lung disease and asthma
• COVID-19 has created a further cohort of patients – those with post-COVID-19 syndrome – who will benefit from pulmonary rehabilitation

Skill mix, competencies and training

Skill mix

Pulmonary rehabilitation has the benefit of clear, evidenced-based guidance on the skill mix MDTs require across registered and non-registered staff operating at different levels of practice to deliver the minimal components of pulmonary rehabilitation services [11–12].

All pulmonary rehabilitation MDTs must maintain appropriate competencies and clinical experience, with the whole team receiving regular updates and training to deliver safe, effective pulmonary rehabilitation programmes for people with a variety of needs.

All pulmonary rehabilitation services are required to have a competency framework to ensure this is the case [11]. A useful resource for developing a framework may be the NHS England London Region pulmonary rehabilitation capabilities framework, launched on 5 September 2023.

All MDT members must be enabled to work to the top of their scope and capabilities, and supported to develop in their careers. The British Thoracic Society (BTS) Workforce and Service Development Committee is developing a high-level professional framework to support the training and development for those pursuing a career and working in pulmonary rehabilitation; this is due for publication in 2024.

Systems need to be in place to evidence the competencies of individual staff members.

Staffing levels must be sufficient to allow time for training and professional development of all team members, paid and unpaid, registered, non-registered, and to provide practice-based learning for students and apprentices.

Suitably qualified healthcare professionals

The Pulmonary Rehabilitation Services Accreditation Scheme standards provide guidance on suitably qualified healthcare professionals within MDTs and to supervise the exercise component. They can be from different professional backgrounds provided they have the right competencies and the appropriate clinical supervision. Broadly, this means anyone with a professional registration (Health and Care Professions Council (HCPC) or equivalent) and who has completed the postgraduate BTS fundamentals of pulmonary rehabilitation course (or equivalent).

They may be statutorily regulated clinicians, such as physiotherapists, occupational therapists and nurses, registered with the HCPC or the Nursing and Midwifery Council. They may also have advanced practice clinical capabilities, such as those for running diagnostic tests, prescribing medicines or issuing fit notes.

Those from professions that do not hold statutory regulation, such as sport rehabilitators and clinical exercise physiologists, should be registered with an accredited non-statutory register, such as the Registration Council for Clinical Physiologists or British Association of Sport Rehabilitators, which are both public registers.

For information about the different exercise professionals, see Choosing your workforce – regulation and exercise specialists, one of the NHS England Pulmonary Rehabilitation Programme outputs on our FutureNHS page.

Non-registered healthcare staff

The non-registered workforce has a vital role in delivering rehabilitation programmes, including healthcare assistants/support workers, rehabilitation assistant practitioners, nurse associates and non-registered exercise professionals.

Administration

Administration and tech support are essential to the efficient running of the service, freeing up clinical staff time, and needs to be sufficiently staffed.

Core competencies

Pulmonary rehabilitation MDTs need to include staff with the competencies to deliver the different components of the pulmonary rehabilitation programme safely, effectively and in a personalised manner.

Every member of the team needs to have some of the competencies; others are for specific roles.

Many of the competencies are specific to pulmonary rehabilitation but some can be gained from experience and training in other pathways and clinical populations.

For assessment, competencies are required to:

• holistically assess patient safety for exercise training and exercise capacity, including knowledge of red flags, contraindications and precautions, and carry out a validated, standardised exercise test in line with field walking tests standards [13] to obtain an individualised exercise prescription as part of the assessment
• assess the needs of patients with COPD and other chronic respiratory conditions (for example, bronchiectasis, interstitial lung disease, asthma and post-COVID-19 syndrome); patients with cardiorespiratory diseases (such as pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension), cardiovascular disease (including chronic heart failure); and patients waiting for lung cancer and lung transplant surgery, and oxygen users
• document vaccination and smoking/vaping status, resting oxygen saturations, heart rate and blood pressure measurements, nutritional assessment, frailty, presence of anxiety and depression, and disease knowledge
• identify unexplained symptoms that could indicate undiagnosed cardiovascular disease, such as chest pain or intermittent claudication, elevated blood pressure or arrythmias, and refer for further evaluation
• assess for suitability for lung volume reduction surgery

For exercise classes, competencies are required to:

• deliver individualised exercise prescriptions for endurance and resistance training
• regularly supervise endurance and resistance training
• support alternative pulmonary rehabilitation models, particularly those involving digital technology

For education, competencies are required to:

• deliver a structured and comprehensive programme of education on chronic respiratory disease and related symptoms
• deliver the relevant topic areas – including medication, oxygen therapy, breathing control, exercise and nutritional advice

For discharge, competencies are required to:

• assess patient outcomes
• provide an individualised, structured, written plan for ongoing exercise maintenance
• refer or signpost to community activities and services that support a person to maintain their exercise programme

Core training

The MDT’s training needs will depend on the competencies team members already have, and the needs of the population, service and pathway.

This is likely to include:

• specialist training in pulmonary rehabilitation, such as the BTS/Association of Chartered Physiotherapists in Respiratory Care (ACPRC) fundamentals of pulmonary rehabilitation and advanced pulmonary rehabilitation courses
• safeguarding
• managing risk, complexity and needs of people with multiple conditions
• quality improvement (QI)
• inclusive access and cultural competence, reflecting the diversity of local populations
• exercise prescribing
• motivational interviewing
• personalisation
• shared decision-making
• data collection
• managing acute events or deteriorating patients

Other training might include psychological support and provision of hybrid services/digital competency.

Pathway development and new ways of working

Pulmonary rehabilitation MDTs will need to adapt their pathways to integrate them with new respiratory diagnostic hubs, virtual respiratory wards and COVID-19 clinics, developing new relationships and protocols.

They need to factor in time to build relationships with new teams on the pathway and give consideration to some MDT members working across wider teams; for example, pulmonary rehabilitation clinicians with advanced practice skills undertaking diagnostics or rehabilitation assessments for patients with complex needs on virtual wards.

The MDT’s role in improving and streamlining the respiratory pathway should also be considered. This has implications for the MDT skill mix; for example, employing clinicians with the competencies to deliver and issue fit notes and prescribe, to eliminate the need to refer patients back to GPs for these purposes.

Many pulmonary rehabilitation services are already exploring ways to redesign services to better meet population needs. For example:

• training volunteers – former patients and their carers – to support patients to take up and complete programmes, and to enhance pulmonary rehabilitation programmes with activities that support self-management/maintenance and community outreach
• integrating elements of provision with services for people with other long-term conditions, such as cardiac rehabilitation and falls prevention
• sharing staff across rehabilitation teams to increase flexibility and build skills
• offering services to a wider population group (Medical Research Council score 2*), taking a preventative approach and reaching patients for whom work is a barrier to participation
• using the learning from the COVID-19 pandemic to provide successful hybrid in-person and online services

All service model innovations will have implications for the skills mix necessary for a safe and effective multidisciplinary pulmonary rehabilitation team. For example, when introducing digital technology (that is, remote monitoring and online provision), the staffing and competencies required to make this effective and inclusive for patients will need to be considered. As more evidence emerges on new models, guidance on competencies, skill mix and staffing levels may be revised.

Safe and effective staffing levels

Staffing levels need to rise incrementally as appropriate referrals increase and services more effectively retain patients to complete their pulmonary rehabilitation programmes.

Commissioners and service providers should estimate the minimum staffing required per 1,000 people who are referred and start the course. This estimate should be based on an assessment of staffing required to meet the requirements of the Royal College of Physician’s Pulmonary Rehabilitation Services Accreditation Scheme, including number and length of sessions, and BTS guideline on pulmonary rehabilitation in adults. This guidance does not inform requirements for registered and non-registered staff operating at different levels of practice, but the required levels of these staff will need to be factored into calculations.

NHS England has commissioned a minimum staffing calculation based on the considerations below. This will be incorporated into the pulmonary rehabilitation modelling tool.

Services are developing new ways of working to increase capacity and accessibility of services; for example, adopting integrated models and hybrid delivery models. As evidence for new models emerges and future BTS quality standards for pulmonary rehabilitation are informed by its clinical statement on pulmonary rehabilitation, revised guidance on staffing levels and competency requirements may be needed.

The optimal ratio of statutory regulated professionals, other registered professional groups and non-registered staff will vary between pulmonary rehabilitation programmes. It will depend on the needs of patients (acuity, oxygen users, multiple conditions, disability) and the pathway, as well as the levels of experience and competence within the team.

Calculation should be based on the population need, with additional required staffing dependent on patient acuity, number of oxygen users, size of classes and the length of programme, as well as the training and supervision needs of the team.

Staffing needs to be sufficient to avoid lone working; classes should never be run by a single member of staff.

The staffing calculation also needs to include staff time for training and development, practice based learning and time for students and apprentices, leading or contributing to research and quality improvement in line with the latest evidence, accreditation preparation, outreach and team meetings. Additional time needs to be factored in to provide the NHS England recommended levels of support for newly qualified clinicians (preceptorships).

With the benefits of integration well understood, building relationships across the pathway and with other pathways is important. Time for this needs to be factored into the staffing calculation – for example, to participate in respiratory and rehabilitation networks; to build relationships with primary care to improve the rate and quality of referrals from primary care; to work in an integrated way with new diagnostic hubs and virtual respiratory wards; to enable partnerships with the voluntary sector, faith groups, leisure services and others to support maintenance of physical activity levels.

Developing the future workforce

All pulmonary rehabilitation services are accountable for developing the future workforce through providing placements for students and posts for newly qualified clinicians.

Ensuring roles for newly qualified clinicians is in the service’s interest, as they can make a valuable contribution to delivery. Exposure in early careers to respiratory rehabilitation will also inspire more clinicians to work in pulmonary rehabilitation and, more broadly, will help develop the respiratory expertise needed in all clinicians.

All pulmonary rehabilitation services should be taking students on placement: pre- registration statutory regulated professionals; pre-registration accredited registered professionals; exercise professionals; and medics on observational placements. This is not only because pulmonary rehabilitation services rely on a growth in the workforce supply, but also because given the right support students too can contribute to delivering services. See the Chartered Society of Physiotherapy and Royal College of Occupational Therapists’ Principles of practice-based learning.

Providing career progression in pulmonary rehabilitation services supports workforce retention, and grows workforce supply and the necessary skill mix. For registered staff this means apprenticeships to develop enhanced and advanced practice skills. For non-registered staff this means apprenticeships for rehabilitation assistant practitioner and nurse associate qualifications, and the opportunity to move into registered clinical roles through degree apprenticeships. This includes pre-registration masters for non-registered staff who already have a relevant degree.

Resources

• NHS England. Pulmonary rehabilitation programme outputs (workforce) 2023, on the FutureNHS Collaboration Platform
• NHS England London Region. London region pulmonary rehabilitation capabilities framework
• BTS Clinical Statement on Pulmonary Rehabilitation, 2023
• Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, Elkin SL, Garrod R, et al (2013). British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 68 (Suppl 2): ii1–30
• British Thoracic Society. Short courses
• Royal College of Physicians (2020) Pulmonary Rehabilitation Services Accreditation Scheme, Accreditation standards and guidance for the public
• Establishment setting guidance – clinical workforce productivity (safer staffing tools and guidance), on the FutureNHS Collaboration Platform
• Chartered Society of Physiotherapy and Royal College of Occupational Therapists (2022). Principles of practice-based learning. Working together to develop our future workforce

References

1. Royal College of Physicians (2018). COPD – working together – clinical audit 2017
2. Royal College of Physicians (2020). Pulmonary rehabilitation clinical and organisational audits 2019: Clinical (patients assessed for PR between June and November 2019) and organisational audits of pulmonary rehabilitation services in England, Scotland and Wales 2019
3. The Health Foundation (2018). Understanding the health needs of people with multiple conditions
4. Wang JJ (2021). Risk of coronary heart disease in people with chronic obstructive pulmonary disease: a meta-analysis. Int J Chron Obstruct Pulmon Dis 16: 2939–44
5. National Institute for Health and Care Research (2021). Multiple long-term conditions (multimorbidity): making sense of the evidence
6. Kingston A, Robinson L, Booth H, Knapp M, Jagger C (2018). Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age Ageing 47(3): 374–80
7. Adab P, Jordan RE, Fitzmaurice D, et al (2021). Work package 3: chronic obstructive pulmonary disease and occupational performance. In: Case-finding and improving patient outcomes for chronic obstructive pulmonary disease in primary care: the BLISS research programme including cluster RCT Southampton (UK): NIHR Journals Library
8. Asthma + Lung UK (2022). COPD in the UK: delayed diagnosis and unequal care
9. Steiner MC, Lowe D, Beckford K, Blakey J, Bolton CE, Elkin S, et al (2017). Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales. Thorax 72(6): 530–7
10. Stone PW, Hickman K, Steiner MC, Roberts CM, Quint JK, Singh SJ (2021). Predictors of pulmonary rehabilitation completion in the UK. ERJ Open Res 7(1)
11. Royal College of Physicians (2020). Pulmonary rehabilitation services accreditation scheme: accreditation standards and guidance for the public
12. Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, Elkin SL, Garrod R, et al (2013). British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax 68 (Suppl 2): ii1–30
13. Holland AE, Spruit MA, Troosters T, Puhan MA, Pepin V, Saey D, et al (2014). An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J 44(6): 1428–46

Publication reference: PRN01037