ICS respiratory review - pulmonary rehab (PR)

Wiltshire  

• Increasing rolling programmes offered in areas of greatest deprivation.  
• Doubling the weekly availability for programmes from post-lockdown status.    

BaNES  

• Undertaking a pilot with one surgery with under-represented patients initially to try to engage, and using the learning from this to develop a strategy and method of helping patients in other surgeries where inequalities are low.

Swindon  

• Planning for extra courses and changes to the service delivery model in 2023 in order to double capacity for each group, in addition to doubling the places from last year – the venues selected are in the most deprived areas of Swindon (Penhill, Pinehurst and Walcot).
• Since May, the service has been running 4 cohorts at any one time, and these are scheduled to continue throughout the year.
• Through the successful development and implementation of a Virtual program, the service is now able to offer PR to people who otherwise would not have accessed it. This has received excellent patient feedback.  
• Have adapted the recruitment process to ensure that all patients referred are offered the chance to discuss potential barriers to attending PR including language, communication difficulties, transport issues, social anxiety etc and we actively look for solutions to enable the patient to attend if they wish to.  
• Since May 23, have been running an Opt-In session for all potential patients to improve attendance and commitment to the course. The Opt-in trial sessions have proved successful so far, leading to the recruitment of an entire course. The DNA rate at the assessment day was 30% lower. 26 out of 27 people attended after opt-in (96% attendance). This is compared to the previous course, prior to opt-in 18 out of 27 people attended (66% attendance).  
• Have started a promotion drive, including the creation of a promotional leaflet which will promote the opt-in sessions.
• Promoting the pulmonary rehab service to hospital consultants and in-reach team and plans are in place to extend this local GP groups., with the aim of improving accessibility of PR for those who have barriers to attending. 

The ICB commissions a community-based PR service aimed at improving attendance and completion among targeted population cohorts.

Improving PR capacity is part of the BOB ICS Respiratory Plan. 

PR information and resources shared via GP gateway and individual practice communication. HCAs complete calls prior to the patient's first assessment. PR providers are utilising band 3 and 4 staff to support PR classes. 1 Provider has instituted rolling programmes, another has put in place pre-assessment information sessions which have had a positive effect on DNA rates. 

Single service specification to reduce variation and focus on high risk patient groups. Education session on regional and specific to local GP practices with focus on low referrers. Menu of options available for patients to access services in different ways. Trialling digital options.

Testing using population health dashboard to identify patients not accessing PR who might be most in need and reaching out to them.

NHSE Funding is being used by Providers to recruit additional PR staff and restart the National PR Audit.  This supports the reduction of PR waiting lists and waiting times, reduces the number of GP appointments and hospital admissions, and supports a reduction in length of stay.

We are developing a PR PHM dashboard to enable us to proactively manage our population – identify areas with low referrals/ poor uptake, assess improvements as a result of interventions, identify patients missing out on PR referrals etc.

We are always reviewing the locations of our PR to optimise attendance and address capacity shortfalls

We are undertaking COPD projects in 3 PCNs to increase referrals.

Working with Interface clinical services for face-to-face reviews and referral as needed to PR; local events to raise awareness of PR generally; GP protected learning time to raise awareness 

• We have a dedicated project working with the PR team within the respiratory clinical programme group to improve PR referrals, attendance and completion rates.  
• The community trust (PR provider) are dedicating resource to achieving their accreditation.  
• We have introduced rolling cohorts to increase capacity and reduce waiting lists.  
• We have assessed locations of courses to ensure they are in the right places to be accessible for all.  
• We are encouraging the uptake of online courses and those delivered out of hours. 

Pulmonary Rehabilitation group is set with all the acute trusts across all the localities and is working to get them towards accreditation to improve PR Referral, attendance and completion.

Actions NHS Hampshire and Isle of Wight are taking include:

• Utilising national Service Development Funding (SDF) in line with the NHS Long Term plan to expand pulmonary rehabilitation capacity. This has included things like funding additional exercise professionals to expand service capacity. In 2023/24 this increased completions by over 200.
• Introducing a new virtual model across Hampshire and Isle of Wight integrated care system to introduce better choice and support access to pulmonary rehabilitation.
• Additional capacity for people who may experience barriers to accessing pulmonary rehabilitation, for example people with complex health needs, those residing in prison, and local pop-up clinics for people from particular health inequality groups.

Both our attendance and completion rates have increased due to these actions. 

5 year PR plan. Outreach into community venues for PR closer to home. Engaging with farming communities via farming shows (e.g. stand an Hanbury show). Drop-in education sessions for primary care and Neighbourhood Team to enhance quality and quantity of referrals into PR. Signed up to IMPROVE trial to have PR 'buddies'/peer support workers support patients through their PR journey and enhance attendance. 

• Access to PR included in Respiratory Clinical Network Workplan as core objective.
• NHSE PR monies fund unique initiatives across services to improve referral, attendance and completion rates, in addition to targeting health inequalities. We are working with local commissioners to monitor the effectiveness and impact of these initiatives.
• Report to support robust and equitable provision of PR is in development. Draft to be shared for feedback at PR leads. 

Increased awareness and education of primary care, changes to referral forms to make it more accessible, comms in the GP bulletin, new videos for patients of what PR is etc 

The ICS has a 5 year PR plan in place. PR teams working towards RCP accreditation. Each PR team has plans to address access for deprived communities. 

New commissioned service aligned to BTS, targeted at reducing waiting list and providing a digital service (booking  referrals support etc.).

There are a number of strategies in place. The aim of NCL is to:  

• increase appropriate and eligible referrals
• understand reasons for low uptake (quant and qual data collection)  
• collect data on drop out reasons  
• apply a system standard for data management including ‘completions’ to ensure accuracy of data  
• (TBC) collaborate with City Uni to complete MSc research studies x2 into drop out reasons 
• Work with NCL Training Hub/NCL Faculty and Federations to promote understanding of PR and referrals (activity TBD – to align with needs of primary care)  
• Cultural competency – to promote access and uptake. Work already completed on understanding challenges – next steps to turn this into content to promote change in NCL. 

• Dedicated PR lead for NEL
• Increased the capacity of PR services across NEL with the NHSE funding.  
• Working together as an NEL PR Group to build an educational platform to provide consistent messaging about PR.   With the hope to provide translated material in the future.  
• Working with social initiatives such as West Ham Charity to increase access within local communities.  
• Produced videos for both service users and referrers to outline the benefits of pulmonary rehabilitation.  
• Monitoring NRAP data at system level to highlight areas of future investment to improve outcomes.  Although still below the national average, all KPIS are improving year on year.  
• All services are working towards PRSAS accreditation.  
• Services engaged in research, in particular the IMPROVE trial. 

Education during GP protected learning time 

Primary care education via webinars, resources for referrers and patients including leaflets and posters, development of a COPD data dashboard to identify eligible patients. Increasing accessibility by extending geographical reach, enabling flexible scheduling, offering patient transport. 

Outreach clinics, use of myCOPD app, use of gym instructors with level 4 training to support our PR teams. Cross working between both our trusts for PR so that patients aren't waiting excessive times. 

• Active case finding
• Increased promotion of PR across the system
• Hybrid PR offers
• Virtual PR offers
• Referral proforma review
• Buddy system for newcomers
• Thematic analysis of non-completion reasons
• Regular system communications

There is information circulated from the service and the topic is covered at the annual respiratory update day for primary care (including around 140 clinicians). 

• We have used national funding to increase workforce and capacity
• Worked closely with primary care to increase knowledge and understanding of PR to improve rate and quality of referrals including referrer and patient information
• SEL wide project underway to understand specific reasons for drop-outs and planning to address these
• Worked with Vital 5 team to understand mental health and wider determinants of health concerns to improve uptake and completion of PR
• In feasibility stage of plans to provide PR in in-patient mental health facilities 

Accreditation for all practitioners to improve standard.

SY ICS developed an initial SY PR Vision and Improvement Plan in response to the NHSE 5 year vision plan for PR. This outlines 6 priority delivery areas specific to the SY system and is complemented by a PRSAS roadmap. A Provider gap analysis and a health population database was completed to identify areas for improvement. Projects initiated following this have included:

• Additional rehab groups in area of high deprivation
• New post PR service in area furthest away from PR venue
• Health Watch project analysing reason for non-attendance to PR
• Primary Care engagement work to increase knowledge and skills to increase referral rate
• Regional data dashboard specification for Providers
• Regional registration for PRSAS 

New clinics and digital options. 

We have established a Pulmonary Rehab Improvement Collaborative, which brings together the four place-based providers of PR services across Surrey Heartlands. This group has agreed a 5-year PR Improvement Plan, taking into account the NHSE improvement plan and commissioning standards. Actions in train include: each provider continues to review data to understand dropout rates and any patterns, and implement actions in response; to help address health inequalities and improve access, establishing connections with local faith groups, use of the HEAT tool, and participation in  a system-wide ‘hackathon’ with Business Intelligence and Population Health to explore systemwide case finding through a health inequalities lens. 

PR programme.

PR in VR (virtual reality) provides an alternative option for people who don't want to travel.  Transport initiatives.  Different options i.e. face-to-face or remote provision.