New analysis from the National Respiratory Audit Programme (NRAP) – hosted by the Royal College of Physicians (RCP) – highlights improvements in chronic obstructive pulmonary disease (COPD) and pulmonary rehabilitation care but warns of stalled progress in adult asthma and delays in treatment following acute admission.
- 35.9% of COPD admissions are from the most deprived communities
- 37% of patients hospitalised with COPD still smoke
- Only 38% of children receive the recommended treatment of steroids within 1 hour of admission following a severe or life-threatening asthma attack
- The average wait for people with stable COPD to start pulmonary rehabilitation is 100 days
- Only 38.8% of hospitals meet recommended asthma nurse staffing levels.
Care for people with respiratory conditions is improving in some key areas, but progress remains slow and inconsistent across services, according to a new NRAP report, Room to breathe: a longitudinal review of respiratory data. The findings draw on data from around 100,000 hospital admissions and nearly 48,000 pulmonary rehabilitation assessments across England and Wales.
The report shows encouraging signs of improvement in several core aspects of care, particularly for people with COPD, children and young people with asthma, and those referred for pulmonary rehabilitation. These include safer oxygen prescribing, better access to tobacco dependence support and improvements in discharge processes.
However, progress across adult asthma care has remained largely static over recent years, highlighting ongoing challenges in delivering consistent, high-quality care at scale. Delays in treatment continue to be a concern. For example, the median time for patients with acute asthma to receive oral steroids is 3.2 hours, despite evidence that treatment within 1 hour can reduce hospital admissions.
Variation in care also persists. While some hospitals deliver high-quality discharge bundles for asthma, only a small proportion consistently provide them to the majority of patients, and outcomes differ significantly between services. The report also highlights ongoing workforce and capacity pressures across respiratory services. In COPD care, timely access to life-saving treatments such as non-invasive ventilation and specialist review within 24 hours remains below optimal levels.
Tobacco dependence continues to be a major driver of poor outcomes, with around 37% of hospitalised COPD patients still smoking – a figure that has remained largely unchanged over the past decade – although there has been important improvement in people who currently smoke being offered tobacco dependency advice, in line with NICE guidance.
Meanwhile, access to pulmonary rehabilitation is improving but still not timely enough for many patients. Fewer than half are offered a start date within 90 days of referral, despite clear evidence of its benefits in improving quality of life and reducing hospital admissions.
The report finds that, overall, improvements in respiratory care have been modest over the past four years, with only limited gains across many of the programme’s key performance indicators. It calls for renewed focus on implementing proven interventions, including discharge bundles, early treatment in emergency care and system-wide approaches to tobacco dependency, alongside collaboration between specialties to improve care in the crucial first hours of hospital admission.
Professor Alice Turner, NRAP senior clinical lead, said: ‘This year’s data show real progress in some of the fundamentals of respiratory care, from safer oxygen prescribing to better support for people to stop smoking. That reflects the commitment of clinical teams working under immense pressure. But the overall picture is one of uneven improvement. Too many patients are still not receiving timely, evidence-based care, particularly in the first few hours of admission. We know what works, and we now need to see consistent, system-wide delivery of that care across every service.’
Professor Tom Wilkinson, former NRAP senior clinical lead, said: ‘What this analysis makes clear is that progress in respiratory care is possible, but it is not happening at the pace or scale needed. Variation remains a major challenge, and the priority now must be implementation. Interventions such as early treatment and discharge bundles are proven to improve outcomes, yet they are not being delivered consistently. If we are serious about reducing avoidable admissions and improving patient experience, we must focus on embedding these approaches across the whole system.’
The NRAP programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England and the Welsh government as part of a larger national clinical audit programme designed to improve healthcare.
Chris Gush, HQIP chief executive officer, explains more about the value of audit in healthcare: ‘National clinical audits like NRAP measure health services, comparing the care delivered against standards. Covering a wide range of common conditions, they provide robust, clinically validated data, and shine a light on what is working well and what is not. The NHS cannot improve what it cannot see clearly. Audit gives clinicians, providers and systems the evidence they need to focus limited capacity on the interventions that work, reduce avoidable pressure, improve consistency, and deliver greater efficiency across services.’
The NRAP programme continues to support services to use data to drive improvement, with increasing participation across England and Wales. Service participation continues to increase with 676 participating sites in 2023/24 increasing to 690 in 2024/25. Consistent involvement from services allows the NHS to implement data-driven quality improvement activity at site level.
