LTP Priority: Prevention

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: Respiratory

Major driver of health inequalities in your area of work

Respiratory disease affects one in five people and is the third biggest cause of death in the England (after cancer and cardiovascular disease)[1].

Incidence and mortality rates from respiratory disease are higher in disadvantaged groups and areas of social deprivation, with the gap is widening and leading to poorer health outcomes[2].  The most deprived communities have a higher incidence of smoking rates, exposure to higher levels of air pollution, poor housing conditions and exposure to occupational hazards.

The mortality rate for respiratory disease (under 75 mortality rate) in the most deprived deciles is increasing whilst it is actually reducing for the least deprived[3].

Inequalities exist in asthma incidence within different ethnic groups.  There are significantly higher rates of asthma in non-white groups in England and Wales.  The data suggests that non-whites born in the UK, such as second generation South Asian and Afro-Caribbean migrant groups experience higher levels of asthma incidence[4].

An additional factor contributing to the inequality in respiratory disease is the level of health literacy with different sectors of the population.  Disadvantaged socioeconomic groups, migrants, older people, people with mental and physical disabilities and those with long-term conditions are identified as experiencing lower levels of health literacy[5].

Target groups

Deprivation, Inclusion health groups and protected groups


Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment.

(Chronic obstructive pulmonary disease in over 16s: diagnosis and management

NICE guideline [NG115] Published date: December 2018)

Pulmonary rehabilitation (PR) is a multidisciplinary exercise and education programme designed for people with lung disease who experience symptoms of breathlessness.  90% of patients who complete the programme experience improved exercise capacity or increased quality of life[6].

Optimal treatment and management of COPD and breathlessness can reduce acute admissions, reduce exacerbations and increase capacity in primary care.

PR is a high value treatment that results in improved exercise capacity or increased quality of life – but it is only offered to 13% of eligible COPD patients[7].   A Cochrane Review of PR[8] following exacerbations of COPD, showed PR reduced mortality and admissions.

A priority in the NHS Long Term Plan[9] is to expand pulmonary rehabilitation services over the next 10 years, which will result in 80,000 admissions and 500,000 exacerbations avoided.

Referral to PR services will be increased, where this is appropriate through the use of the COPD discharge bundle.


The COPD PRIME tool shows the impact that a physiotherapy-led PR programme has on reducing COPD exacerbations and their associated management in primary and secondary care. It demonstrates that a significant number of admissions to A&E departments and hospitals, can be avoided as a direct result of physiotherapy led PR programmes.

The tool uses sources from: Randomised Controlled Trails (RCTs), Clinical Practice Research Datalink data (CPRD) and the British Thoracic Society (BTS)/Royal College of Physicians (RCP) audit[10].

Guidance for Commissioners

[1] Public Health England, Respiratory disease: applying All Our Health, April 2015

[2] Marmot M (2010) Fair society, Healthy lives: Strategic review of health inequalities in England, post 2010


[4] Netuveli, G. Hurwitz, B. Sheikh, A. (2005) Ethnic variations in incidence of asthma episodes in England & Wales: national study of 502,482 patients in primary care, Respiratory Research,

[5]Public Health England and UCL Institute of Health Equity (2015) Improving health literacy to reduce health inequalities

[6] Royal College of Physicians (2017) National Asthma and COPD Audit Programme (NACAP). Available from:

[7] National COPD Audit (2017)

[8] Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.

Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD005305. DOI: 10.1002/14651858.CD005305.pub3].