Of the 38 potential participants who were invited, 20 consented to participate. Reasons for non-participation included: no longer working in a relevant field, recommendation of colleague considered a more appropriate participant, inability to arrange interview dates and unknown (lack of response). Participants’ median duration of working within healthcare was 13 years (range: 2–30 years) and currently worked across different NHS settings (Table 1) in: London and Home Counties (n = 8), Midlands (n = 2), North-East (n = 2), North-West (n = 3), South-East (n = 4) and Wales (n = 1).

Table 1 Participants’ healthcare setting and roles.

We report our findings under four distinct but related themes (Table 2). Within each theme, sub-themes were identified which explain the findings in more detail. The first theme “Living with COPD and emotional distress affects engagement with physical and psychological services” highlights the perceived complexity of living with COPD and how people need support with both physical and psychological symptoms across healthcare services. The second theme “Resource limitations affects service provision in COPD” underlines the challenges and considerations necessary for service provision such as, accessibility, funding and how services are delivered. The third theme “Provision of integrated care is important for patient well-being” describes the need for holistic services for COPD patients to ensure the most effective care. The final theme, “Healthcare communication can be an enabler or a barrier to patient engagement” highlights stakeholders’ perspectives that the communication about healthcare services (treatments) is a critical part of effective provision. This incorporates communication with those using the services but also within and between professional groups. Key enablers and barriers to psychological interventions like TANDEM are summarised in Table 3.

Table 2 Summary of themes.Table 3 Facilitators and Barriers to successful implementation of psychological interventions in COPD care.Living with COPD and emotional distress affects engagement with physical and psychological services

Breathlessness, the loss of previous activity levels and social isolation were recognised challenges for people with COPD; they were also perceived as experiencing complex co-morbidities including other physical long-term conditions (e.g., cardiovascular disease and lung cancer) but also significant emotional distress including depression and anxiety.

“There will be a cohort of the ones who are really more severe and have very high anxiety and or depression levels who really have a very poor quality of life and find it very difficult to engage in things” Participant 2, Respiratory Consultant

Stakeholders recognised how emotional distress had an impact on people accessing services/treatment, particularly where people are anxious about leaving their home or attending group sessions, or when their depression symptoms affect their motivation and ability to participate.

“You’ve got to get into the service, often you have to be fully engaged in the service before you have access to psychological interventions. And actually, what we’re trying to do often with rehab is to get someone to engage with the service in the first place.” Participant 3, Respiratory Consultant & CCG Commissioner

It was also understood that many people with COPD are managing other difficult issues including “deprivation”, “trauma”, and “messy lives” and might struggle to engage with a psychological intervention. Additionally, it was noted that some people resist encouragement to talk about their mood:

“…patients…really low in mood …I’ve reassured them and said…’Would you like to get some form of help with this?’ And they just go ‘No, I don’t want to talk about it to anyone. No.” Participant 4, Respiratory Physiotherapist

“They do need a different approach and that’s what I mean by what we offer at the moment, it’s very good for the mainstream, but we haven’t got much for those difficult to deal with patients. And usually, the reason is it’s…whatever it is, even if it’s pain or mobility, it’s usually steeped in their mental health, anxiety, depression, that’s fairly entrenched” Participant 14, PR Clinical Lead/Physiotherapist

Resource limitations affects service provision in COPD

As for many LTCs, the provision of healthcare services for people with COPD was described as multi-faceted, reflecting strategic, organisational and resource issues that affected the design and delivery of services.

Resources

Stakeholders described how resources were likely to be an obstacle to implementation and reflected particularly on their time restrictions, indicating the perspective that psychological interventions are seen as an additional service to usual clinical care. With limited resources in primary and secondary care, stakeholders were nervous about their capacity to integrate psychological interventions in their existing practice:

“I think with the workload that it would bring; I think it would be too much for one person with having other duties as well…unless one individual was specifically employed to do this….and nothing else…” Participant 4, Respiratory Physiotherapist

Delivering psychological interventions with less familiar skills and practices requires training, supervision, and rehearsal until they become more experienced and routine. Existing service structures were identified as difficult to change, particularly when working under pressure, which potentially inhibited putting new skills in to practice:

“…this stuff takes practice…and you have to keep repeating the things that you learnt in order make them your default setting…when people go back into their working environments, there’s so much pressure to behave the way they used to…my sense is the desire is there, but the environment doesn’t allow you.” Participant 11, General Practitioner & CCG Commissioner

However, optimism about the future was evident, recognising how such interventions would become a more familiar and standard approach and could be embedded into usual care and complement existing physical health services.

“Some people, if they were more negative might say, ‘What? Not more things to deliver’. But you’d have to make sure that there was enough staff to provide it, because I think it [psychological care] does… it is an extra… But ultimately how that will then feed down, the trickle effect into the wider team, everybody will start to be coming from a more CBT approach.” Participant 14, PR Clinical Lead/Physiotherapist

Resources were also considered in terms of priorities and tangible benefits, with the recognition that patient benefit alone is not enough to ensure commissioning of new service approaches. Some stakeholders made suggestions for alternative ways of delivering psychological interventions that might reduce costs.

“I mean for the patient, it’s about whether they feel better, whether it improves their quality of life. But unfortunately, that’s not enough to create change. …I guess face-to-face CBT at home is probably quite expensive, was one thought…if you could do it by phone it would be much more time efficient, wouldn’t it? And therefore, likely to be cost efficient.” Participant 2, Respiratory Consultant

As IAPT services increased their provision in LTCs, psychological support has become more available for people with COPD. Yet some IAPT services are also under resourced, and resource-driven online services might not be appropriate in this context.

“IAPT is overstretched and in order to meet targets…and also from some very genuine thoughtful reasons there’s a focus on online stuff and groups. However, lots of these populations, they’re older or they’re from minority groups that might mean that actually a group is quite stigmatising, quite threatening. Or they don’t have access to IT, or they just don’t want that sort of intervention. And a lot of them are also housebound or very physically unwell. So, engaging with that sort of service is just by definition really difficult….” Participant 8, Liaison Psychiatrist

IAPT professionals recognised psychological interventions like TANDEM, delivered by respiratory healthcare professionals, as a potential complementary service, particularly to meet the needs of those patients who could not engage with current IAPT provision. However, pursuing additional psychological provision outside of IAPT services was also seen as an obstacle in securing commissioning within respiratory services.

“…you can anticipate in a cost pressured environment; the question will be ‘Why can’t we do this via IAPT’”? Participant 6, Respiratory Consultant

Accessibility

Considering the provision of psychological interventions like TANDEM in usual care, stakeholders described COPD services in the context of geographical variations and how services could be most effectively and efficiently resourced as well as considering patient accessibility barriers. For some regions, where patients’ locations are widely dispersed, the potential for healthcare professionals visiting patient homes was more restricted and unlikely to be resourced. The creation of COPD healthcare ‘hubs’ was discussed by different stakeholders, with aligned services in one community location, providing a holistic service:

“It’s good for things to be in the community, we’re trying to achieve a middle ground between the patients coming a little way and the clinician coming some way…” Participant 3, Respiratory Consultant & CCG Commissioner

Despite the geographical barriers, the notion of visiting people at home was supported by stakeholders who recognised the physical and psychological challenges that many people with COPD experience and also appreciated the benefits that extend beyond the core treatment task:

“…. whereas if you’re able to do home visits that will open up a lot of doors for patients who can’t always get out to many appointments and that. And who struggle to leave the house because of anxiety or depression or any form of psychological problem. That would really help them to build up their confidence. And then make them feel able to then go out and come to pulmonary rehab,” Participant 4, Respiratory Physiotherapist

Moreover, home visits could offer the opportunity for services to understand other surrounding issues such as the social well-being of the patients, which can affect PR uptake.

“…. when people go out to the house you often get all the added benefit of that social interaction…. this person’s really struggling at home, we need to get the social work involved and stuff.” Participant 6, Respiratory Consultant

Cost-efficiency

Limited resources allocated to the management of respiratory disease generally was identified as a barrier to implementation. There was a shared expectation that to be considered for commissioning, an intervention must be able to demonstrate significant reductions in healthcare utilisation in addition to improving patient outcomes:

“The key metrics are going to be, does it reduce hospital admissions…and does it reduce GP visits,” Participant 2, Respiratory Consultant

Concern was expressed, however, about whether any intervention could reduce hospital admissions in a clinical population with the complexity of COPD, where people are often living with multiple conditions and can be very unwell:

“Will it impact on admissions?…very difficult to do…. they’re very, very difficult people to keep out of hospital…that’s the problem” Participant 10, General Practitioner & CCG Commissioner

Stakeholders considered the provision of core COPD services in the context of the NHS long-term plan and described the focus on improved diagnostics (spirometry) and the expansion of PR services, which are considered to be cost-effective, although this is not realised if patients are not able to attend and engage. Priorities and measurable outcomes continued to be cost driven.

“…we know that pulmonary rehab is probably the single most effective treatment for breathlessness and COPD… It’s incredibly cost effective…But the challenges in rehab delivery are getting people to the programme and getting them through to complete…” Participant 3, Respiratory Consultant & CCG Commissioner

Stakeholders recognised that commissioning funds were needed to support people with COPD experiencing anxiety and depression. Stakeholders referred to inconsistent priorities in commissioning and, for some, doubt existed as to whether respiratory was an important funding area.

“I don’t think respiratory is very high on the Government’s agenda. I think historically respiratory is poorly funded when you compare it to other diseases such as heart disease and things.” Participant 9, Respiratory Specialist Nurse

Provision of integrated care is important for patient well-being

Stakeholders agreed about the importance of integrated care. They recognised delays in accessing psychological services, and that patients were not always able or willing to engage with additional services, instead preferring the established relationship with their respiratory healthcare professional. Some psychological services were not considered specialist enough for respiratory patients, with sufficient understanding of the symptom burden of COPD and the physical health care needs and flexibility often required by people with COPD.

“…IAPT still work with mild to moderate presentations, which because of the nature of some long-term conditions they don’t always fit nicely into that box to put it…. I feel that we’re a little bit limited as practitioners and as a service when certainly my experience, what I feel like, within IAPT, when we work with this cohort [COPD] of clients.” Participant 15, CBT Therapist

A multidisciplinary team model was considered an effective approach and stakeholders from psychology services were concerned that if the treatment was not delivered as outlined in the evidence base, that it might be ineffective, and patients might conclude that such approaches won’t work for them.

“…there’s a danger in having too light a psychological treatment. That actually, you don’t provide what the evidence base says you should do. And that, in itself, might put people off psychological work because they may say ‘that doesn’t work’ or ‘it doesn’t work for me’ or whatever…” Participant 16, Clinical Health Psychologist/IAPT Clinical Lead

Stakeholders were positive about respiratory healthcare professionals providing psychological support to their patients. Many respiratory nurses and physiotherapists were perceived to have key psychological competencies in their clinical practice, although it was suggested that not all physical healthcare professionals would be prepared to offer psychological support.

“…they’re actually some of the best placed people to do it, particularly when the mood issue is very much related to the chronic condition that exists, because their knowledge of that condition and the volume of people they see, what’s normal for the illness, what isn’t, how have other people managed it, etc.” Participant 12, General Practitioner

“…individuals within services who are willing to explore new techniques…. a handful of the people who could possibly offer it. Because other staff members felt that it was, I don’t know, wasn’t for them, and didn’t feel like they could deliver it…” Participant 9, Respiratory Specialist Nurse

Queries were raised about how physical healthcare professionals would be supervised and supported as is the norm in psychological services.

“My only concern would be ‘Is that an appropriate and sufficient level of support?’… supervision, so that there’s somewhere that contains the worries and anxieties which can come about from managing a very, very complex caseload…”. Participant 7, Liaison Psychiatrist

Stakeholders supported TANDEM’s aim, objectives, and approach and identified additional factors on which comparable psychological interventions could have a positive impact, such as social well-being. The approach was deemed to be holistic, integrative, empowering, supportive, and complementary of current services.

“So, my instinctive response to it [TANDEM] is, I think it’s superb, I think these are core skills, these are hugely common comorbidities. I think the integrated respiratory team people should have these skills. I think having to put everything into mental health is the wrong way to look at it….” Participant 8, Liaison Psychiatrist

Healthcare communication can be an enabler or a barrier to patient engagement

Communication about healthcare services with both patients and healthcare professionals is a critical part of effective provision—to ensure that patients fully understand what treatments involve and how they can help them manage their COPD, and to address any concerns they might have. When this communication is accurate and clearly understood, stakeholders recognise this as an important step towards patient engagement.

Importance of effective patient communication about psychological interventions

Talking with patients about how thoughts and feelings might relate to their breathlessness has to be carefully explained to validate the symptom burden that many experience. Stakeholders described how patients can respond negatively if they suspect it is being suggested that their breathless symptoms are not real physical symptoms:

“…. you imagine somebody coming and saying ‘Doc, I’ve got really bad COPD, there’s my breathing tests, they’re terrible’. And me saying ‘You know what? You need to go and see somebody about how you feel stressed or not….’ You’re dead breathless, therefore you must go and see a psychologist. Well, that means…’are you denying I’ve got a physical disease?’ ‘Do you think I’m making up all this breathlessness?’“ Participant 6, Respiratory Consultant

Many stakeholders compared the challenge of effectively communicating about psychological interventions with the existing problem of the misunderstanding that surrounds PR and how improving this is also important for uptake to healthcare services and overall patient well-being. Stakeholders considered that referrers do not always explain PR to patients as well as they could, and as such, patients are less likely to engage, although referrers felt the terminology (“pulmonary rehabilitation”) was a barrier in itself to effective communication and requires better explanation.

“So, the whole concept of PR is utterly alien to a patient,” Participant 3, Respiratory Consultant & CCG Commissioner

“I wish we could rebrand it or rename it. I think ‘rehabilitation’ or ‘going to rehab’ is just…it sounds like drink or drugs or…” Participant 19, Respiratory Specialist Nurse

Communication between healthcare professionals

Stakeholders acknowledged that often the communication between healthcare professionals about some services, is also ineffective, which affects uptake and ultimately might affect future commissioning. Recognising the importance of understanding and communicating about services between providers and referrers is an important factor for implementing new psychological interventions in usual care:

“I think healthcare professionals still don’t understand the significance of it,” Participant 9, Respiratory Specialist Nurse

“And so, there’s that issue of convincing commissioners, here’s the evidence, and that’s important to you now, and then there’s the whole thing is we’ve commissioned the service, and nobody turned up. And so, the example that was pulmonary rehab programmes have been commissioned in my area, and they haven’t turned up because the communication hasn’t been very good, through stakeholders like GPs.” Participant 6, Respiratory Consultant