Introduction and objectives There is a sound evidence base which highlights that pulmonary rehabilitation (PR) is an effective management strategy for patients with respiratory disease, in particular COPD. The National PR audit (2015) highlighted a lack of referrals to the programme suggesting that healthcare professionals may not be ‘selling’ PR to patients. However, no evidence exists to fully substantiate this claim; a missing piece of the jigsaw. The objectives of the study therefore were:

1. To explore healthcare professionals’ perceptions regarding referral of COPD patients to PR in primary and secondary care settings.

2. To establish healthcare professionals’ understanding of PR.

3. To explore barriers and facilitators to referral.

Methods Using a phenomenological approach healthcare professionals’ perceptions of PR were explored in relation to understanding and referral. In-depth semi-structured interviews were conducted via purposeful recruitment of general practitioners and practice nurses, and doctors and nurses working on general medical wards. In total 27 healthcare professionals participated; interviews were recorded with the participants consent and transcribed verbatim. Interpretive phenomenological analysis was adopted to determine super-ordinate and sub-ordinate themes regarding participants experiences and perceptions.

Results Three super-ordinate themes emerged from the data: COPD Illness Perceptions, Pulmonary Rehabilitation Beliefs, and Organisational and Referral Pathway Perceptions. A lack of knowledge of PR and the referral process was evident amongst the majority of healthcare professionals interviewed; indeed a number of participants in secondary care had never heard of the programme. It was surprising how many held stigmatising beliefs in relation to COPD, which consequently impacted upon referral practice.

Conclusion Referral to PR is as certain as spinning a wheel of fortune. Chance of referral appeared dependent upon individual healthcare professionals, their perceptions of the programme, views of how COPD affects patients, and opinions of the programme and referral process. All of these aspects, pieced together, could act as a predictor of referral practice.