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Respiratory nurses highlight staffing concerns in COPD care

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Nurses and others working for pulmonary rehabilitation services have seen staffing levels drop and their workload increase amid fears they are struggling to offer timely support to those who desperately need it.

A new report, prepared by the Royal College of Physicians, highlights significant health benefits for those with chronic obstructive pulmonary disease who complete rehab programmes, which can also reduce the need for hospital care.

“There is a concern that staff maybe overstretched which could be affecting waiting times and the standard of exercise tests”

Michael Steiner

However, the report also reveals that many are waiting too long for treatment, with concern staffing shortages are contributing to delays and sub-standard assessments.

The comprehensive audit of pulmonary rehab services in England and Wales shows the total number of services identified decreased from 230 in 2015 to 195 in 2017.

However, this may be a result of programmes merging as the number of patients enrolled remained roughly the same. Meanwhile, the number of staff per service dropped and the amount of work per staff member increased.

The report shows the average number of staff at each service went down from 2.9 whole-time equivalent staff when the audit was first run in 2015 to 2.53 when the exercise was repeated in 2017.

The average number of referrals per staff member went up from 104 in 2015 to 134 in 2017. Initial assessments per staff member increased from 70 to 89 in the same period.

Meanwhile, nearly a quarter – 23% – of service leads in who took part in the 2017 audit reported they did not have enough protected time in their jobs to devote to leadership and developing the service.

“Patients and commissioners can also now begin to use these results in a practical way”

Michael Steiner

Professor Michael Steiner, national COPD audit clinical lead for pulmonary rehabilitation and a consultant respiratory physician, confirmed there was concern that staff were “over-stretched”.

“There has been an overall reduction to pulmonary rehab programmes yet the number of patients who enrolled are still the same,” he told Nursing Times.

“Despite a drop in staffing levels, the quality of care has not deteriorated. However, there is a concern that staff maybe overstretched which could be affecting waiting times and the standard of exercise tests.”

When it came to funding the RCP said this was “inadequate” for some services. The audit found one in five was operating with fixed-term funding and in 60% of cases that funding was for two years or less.

The report also shows not all people with COPD are getting timely support. Waiting times from referral to a rehab programme to actually being enrolled “remain too long for such an effective and high value therapy”, said the document.

In 2017 just 60% of people referred to pulmonary rehab were enrolled within 90 days - down from 63% in 2015.

Meanwhile, more than a third – 38% – did not complete the course of treatment once they had been assessed.

The report also found routine exercise assessments were not up to scratch for more than half of patients.

Nevertheless, it also found some improvements including a slight increase in the proportion of people who actually complete programmes.

Other encouraging trends include the fact 84% of services now provide patients with a written exercise plan on discharge compared to 65% in 2015.

The RCP has called for pulmonary rehab services to enrol 85% of patients referred for pulmonary rehab within 90 days and says services need to ensure exercises assessment are done in line with recommended standards.

“It will also be crucial that pulmonary rehab services are sufficiently resourced to meet this demand”

Lisa Davies

It wants to see at least 70% of patients who are assessed to go on to complete rehab programmes.

Health system leaders, such as clinical commissioning groups and sustainability and transformation plan (STP) groups, “should ensure that pulmonary rehab services receive funding of sufficient quantity and duration to enable them to recruit and retain highly trained staff and develop processes to ensure that all patients are enrolled to PR within 90 days of receipt of referral”, said the report.

The RCP also called for action to address ongoing low referral rates to rehab services from both primary and secondary care.

Dr Lisa Davies, chair of the British Thoracic Society (BTS), said the audit was important when it came to understanding the quality of care in pulmonary rehab and the way services were run.

“We are pleased to see that there is an overall adherence to the BTS standards yet further action should be taken to increase referral rates of eligible patients,” she said. “It will also be crucial that pulmonary rehab services are sufficiently resourced to meet this demand.”

Professor Steiner also hoped the findings would help boost access to services and improve care for people with COPD.

“Patients and commissioners can also now begin to use these results in a practical way to understand the quality of their local services,” he said.

The National COPD Audit Programme brings together a range of experts, including nurses, from primary and secondary care, and pulmonary rehab, and patients.

It is led by the RCP working with partners including the BTS, Primary Care Respiratory Society UK, British Lung Foundation and Royal College of GPs.

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