NNHIP West Leicestershire COPD Programme
Project overview, including who was involved in the project
West Leicestershire was selected as one of 43 sites nationally to participate in Wave 1 of the National Neighbourhood Health Implementation Programme (NNHIP). Building on the INTERSTELLAR project, our previous respiratory multidisciplinary team (MDT) pilot initiative, and prior work within the Federations, the programme now focuses on improving outcomes for patients with Chronic Obstructive Pulmonary Disease (COPD). We are initially prioritising housebound patients, defined pragmatically as those on each practice’s housebound register or identified as unable to routinely attend the GP surgery due to significant mobility or transport issues. While we acknowledge that the precise definition may vary slightly between practices and federations, this approach provides a practical starting point for implementation. We plan to expand to the wider COPD group once the initial reviews have taken place and lessons have been learnt. The programme operates across three GP Federations: Charnwood GP Network, Northwest Leicestershire GP Federation, and Hinckley and Bosworth Medical Alliance, serving over 350,000 patients.MDTs are core to our approach and operate across all three federation areas. Each MDT includes primary care clinicians who present a primary care perspective on patient care and other coexisting illnesses, such as cardiovascular disease and chronic kidney disease (CKD) and secondary care specialists from University Hospitals of Leicester (UHL), who provide expertise in complex respiratory care. GP practice representatives ensure a practice perspective, and the Local Area Care Coordinator supports service coordination. Social prescribers support the wider determinants of health, addressing social factors that impact well-being. Medical Directors from each federation provide primary care clinical leadership: Dr Leslie Borrill (Charnwood GP Network), Dr Kirk Moore (Northwest Leicestershire GP Federation) and Dr James Ogle (Hinckley and Bosworth Medical Alliance), who focus on optimally integrating resources across the three federations, supported by their respective managers and administration staff.
The MDTs review existing care plans and develop new, personalised care plans for COPD patients, ensuring coordinated, proactive care that meets specific patient needs using a neighbourhood perspective. By starting with housebound patients, we are prioritising those facing the greatest barriers to routine care. Each Federation has around 130–150 housebound COPD patients; individual practices range from 1–5 up to 10–20 patients each. We anticipate completing reviews of this cohort in the initial phase. While patients are not present at MDT meetings, their perspectives will be actively incorporated through close collaboration with public health partners. This approach ensures care is delivered in partnership with patients rather than simply to them, allowing their experiences to shape continuous service improvement. Data on Emergency Department (ED) attendances and GP contacts will be systematically collected to evaluate the effectiveness of our interventions and to clearly demonstrate the transition from reactive to preventive care, which is central to the NNHIP vision, both before and after implementation.
To ensure patient perspectives are systematically captured, we are partnering with the University of Leicester and Leicestershire County Council Public Health team on a qualitative research study exploring how adults from underserved communities perceive and manage chronic respiratory illness. This ethically approved study, running from January to July 2026, will conduct in-depth interviews with patients focusing on health beliefs, self-management experiences, and barriers to accessing care. The research builds on previous feasibility work in Charnwood involving community outreach events and focus groups with respiratory patients. Findings will directly inform service improvement and help address health inequalities – a core NNHIP objective.
Who was involved in this work/project?
Dr Leslie Borrill – Medical Director, Charnwood GP Network; Programme Lead
Dr Kirk Moore – Clinical Director, Northwest Leicestershire GP Federation
Dr James Ogle – Clinical Director, Hinckley and Bosworth Medical Alliance
Dr Irene Valero-Sanchez – Respiratory Consultant, University Hospitals of Leicester (UHL)
Dr Onyeka Umerah – Respiratory Consultant, University Hospitals of Leicester (UHL)
Leicestershire Partnership NHS Trust (LPT) – Community respiratory services, with staff attending MDTs to facilitate increased referrals for pulmonary rehabilitation, access to mental health support for anxiety, and promotion of increased physical activity through VSCE colleagues.
Local Area Care Coordinators
Social Prescribers – Federation-based social prescribing teams
Federation Staff - Management and administrative.
GP Practice Representatives – Clinical leads from participating practices
Integrated Care Board (ICB) - staff, including NNHIP coaches
Anna Murphy - Consultant Respiratory Pharmacist (UHL)
Dr Bharathy Kumaravel – Consultant in Public Health, Leicestershire County Council (research partnership lead)
University of Leicester – Centre for Ethnic Health Research and Department of Population Health Sciences (research partnership)
Project outcomes/impact
The NNHIP West Leicestershire COPD Programme aims to improve integrated care and quality of life for patients with COPD. As a Wave 1 NNHIP site, our outcomes support the national goal of shifting care from hospitals to communities and treatment to prevention.A key outcome is the development and implementation of personalised care plans for COPD patients through our MDT approach. By assessing and modifying care plans when necessary, we aim to provide proactive, coordinated care that prevents crises and avoidable hospital admissions. Including social prescribers in the MDT addresses broader health determinants, such as social isolation and housing conditions, which often affect housebound patients more.
Another important outcome is establishing consistent MDT working across all three federation areas, creating a scalable model for neighbourhood health delivery. MDTs will run weekly across the three federations, with the main limitation being the availability of staff who work across MDTs, particularly secondary care consultants. Operating across Charnwood, Northwest Leicestershire, and Hinckley and Bosworth allows us to learn how to adapt the model to different population needs.
We will collect baseline data on key metrics, including ED attendance and GP contacts for enrolled patients, to demonstrate the effectiveness of proactive care planning in reducing unplanned healthcare use. The reduction in ED attendance that would constitute "success" is yet to be determined and will be informed by initial data and stakeholder consensus. Aligning data across primary, secondary, and social care systems poses challenges due to differences in sources, formats, and data-sharing agreements. Despite these complications, establishing a baseline is a priority for impact measurement. This evidence will support sustained investment in neighbourhood health models and support national learning through the NNHIP programme.
Aligned with the NHS 10 Year Health Plan and NNHIP objectives, a key long-term outcome is to show that proactive, neighbourhood-based care for COPD patients can reduce health inequalities and improve outcomes. By starting with housebound patients, who often have the greatest need and fewest resources, we seek to demonstrate that targeted, MDT-led interventions can enhance quality of life and healthcare use, supporting wider adoption for other long-term conditions.
Looking ahead, we recognise that administrative tasks can limit the number of patients reviewed and the effectiveness of MDT meetings. Federations have already been supporting scribes in primary care. As part of our commitment to continuous improvement, we plan to explore how AI-powered tools—such as ambient scribes—might streamline documentation within MDTs, enabling us to scale our approach, improve efficiency, and achieve greater impact.
We aim to embed the MDT model into routine federation working to ensure sustainability beyond the NNHIP programme period.