In celebration of Pulmonary Rehabilitation Awareness Week, we spoke with Nicola Roberts to gain insight into the challenges faced by patients and services in Scotland when accessing pulmonary rehabilitation. Thank-you to the Scottish services for sharing their experiences, and to Nicola Roberts for bringing these stories together.

Improving access to PR: Scottish perspectives

For Pulmonary Rehabilitation Awareness Week, we were asked to share a Scottish perspective on the barriers to access that are faced by pulmonary rehabilitation services and patients. 

In Scotland, we’re fortunate to have the Scottish Pulmonary Rehabilitation Action Group (SPRAG), which includes representatives from each health board. SPRAG is supported by Chest Heart and Stroke Scotland, who provide invaluable administrative assistance. We meet several times a year online, creating a valuable forum for sharing best practices and fostering collaboration.

Each June, we host an annual conference that welcomes anyone with an interest in pulmonary rehabilitation—whether attending in person or joining virtually.

In preparation for this year’s pulmonary rehabilitation awareness week, we asked our regional leads to share their insights on key challenges such as referral and engagement. We also invited them to highlight innovative approaches and initiatives that we can showcase and learn from. 

Barriers to referral

Several challenges have been identified in the referral pathways for pulmonary rehabilitation (PR). Many individuals living with long-term respiratory conditions reported never having been referred to PR, leading to understandable frustration. In some cases, referrals were repeatedly made for the same patients, while others were overlooked entirely.

A significant barrier appears to be the lack of consistent annual reviews in some areas, resulting in missed opportunities to refer eligible patients. There continues to be a gap in awareness and understanding among some healthcare professionals regarding both the referral criteria and the process for pulmonary rehabilitation. This is often compounded by limited familiarity with the service itself and the benefits it can offer to patients, which may contribute to under-referral or missed opportunities for engagement.

Patients themselves often have little understanding of what pulmonary rehabilitation entails, which can make it challenging to encourage participation. Furthermore, frequent staffing changes, reliance on locum staff and unfilled respiratory posts have all contributed to inconsistencies in referral practices and reduced access to PR services.

Barriers to engagement in PR classes

These barriers are likely not unique to Scotland and are commonly experienced within pulmonary rehabilitation (PR), both nationally and internationally. One persistent challenge is the location of PR classes, which often require participants to travel—something particularly difficult for those living in rural areas. Transport can be a major hurdle, with limited public options, long distances, and high taxi costs making attendance difficult for some. Even when transport is available, accessibility from transport links to venues can be problematic.

Venues themselves vary, with some located in hospitals where parking can be limited or costly; the availability and timing of venues can also pose challenges. In addition, staff often face constraints around clinical and desk space, which can impact service delivery and planning.

Pulmonary rehabilitation patients often face complex health challenges, and it’s not uncommon for individuals to drop out due to changes in their health or personal circumstances, including mental health concerns. Many potential participants also lack a clear understanding of what PR involves and may hold misconceptions about exercise and their condition—commonly believing that breathlessness means they are unable to exercise, which can lead to fear or avoidance.

These misconceptions can be reinforced by limited or unclear information provided at the point of referral. In some cases, patients may not have fully come to terms with their diagnosis or the limitations it brings. It’s also been observed that some individuals, particularly women, may not prioritise their own health needs.

Additionally, several services have reported that several patients are reluctant to take part in group-based sessions, preferring not to engage in a group setting.

Plans to address barriers

Our regional leads have shared information about the ongoing efforts within their services to boost participation in PR. These include introducing new and more accessible venues, providing education to colleagues across other services and clinical areas, and raising patient awareness about what pulmonary rehabilitation entails. In addition, they are undertaking a range of broader initiatives aimed at enhancing the overall service, as outlined in more detail in Table 1.

 Table 1 Adaptations to PR to overcome barriers

Regional leads also highlighted the ongoing impact of the COVID-19 pandemic, particularly the loss of suitable rehabilitation spaces and the increased competition for existing facilities. In some areas, access to gym spaces was lost during the pandemic and has proven difficult—if not impossible—to recover. One lead noted, “PR staff are brilliant and working with limited resources,” a sentiment that likely resonates across all regions. Staff have shown remarkable adaptability in continuing to deliver services despite these constraints.

The value of the Scottish Pulmonary Rehabilitation Action Group (SPRAG) was also emphasised, especially during the pandemic, as a supportive and collaborative network. It would be valuable to learn more about similar regional networks and teams supporting PR in other parts of the UK and beyond.

Thank-you to the Scottish services who openly shared their insights into the barriers they face in accessing pulmonary rehabilitation, as part of Pulmonary Rehabilitation Awareness Week.

To continue the conversation, we’re hosting a Community of Practice session on Thursday 19 June, focused on improving access to PR. This will be an opportunity to explore common challenges and share strategies with colleagues in PR.

Register here to join the discussion and be part of the RCP community of practice for pulmonary rehabilitation.