South Hampshire Integrated Find and Treat Airways disease (SHIFT-AIR) Programme
Project overview, including who was involved in the project
The Health Innovation Network – Respiratory Transformation Partnership (HIN-RTP) funded SHIFT-AIR programme builds on over a decade of collaborative working between primary, community and secondary care partners across the region. It also draws on learning from the NHS England 2024/25 Winter COPD OPTIMISE project delivered in Southampton. This earlier work demonstrated that proactively identifying and optimising care for rising-risk COPD patients, supported by digital health tools, can improve respiratory care. This success provided the foundation for SHIFT-AIR, enabling the programme to expand these approaches into a broader, system-wide model for respiratory transformation.The initiative is delivered by primary care teams in collaboration with integrated community respiratory services & secondary care specialists. Third-sector organisations are also key partners, particularly those supporting people experiencing fuel poverty and wider social determinants that affect respiratory health. The programme also further strengthens patient support by expanding access to digital self-management through the NICE approved MyCOPD app.
A central aim of SHIFT-AIR is to embed proactive case-finding and rising-risk management within routine primary care workflows. Using targeted searches within EMIS and SystmOne, practices identify patients who may have undiagnosed asthma or COPD and refers them to community diagnostic hubs for further assessment.
For patients with COPD at risk of exacerbations, the programme has co-developed the SCOPES Post-Exacerbation Toolkit with the South East ACT on COPD group. Embedded with primary care systems, SCOPES supports delivery of high-value interventions aligned with quality and outcomes framework (QOF) and local incentives, including smoking cessation support, medication optimisation, pulmonary rehabilitation (PR) referral and enhanced self-management support.
Project outcomes/impact
The SHIFT-AIR programme has delivered significant transformation across the respiratory care pathway by embedding proactive case-finding and rising-risk management into routine primary care workflows. Targeted searches identify patients at risk of asthma and COPD, supported by review of GP coding to improve diagnostic accuracy and referral to community diagnostic hubs where further testing is required. Since November 2025, this approach has led to 960 new asthma diagnoses and over 1,100 new COPD diagnoses, enabling earlier intervention.A key element of the programme is the SCOPES Post-Exacerbation Toolkit, now integrated directly into primary care systems. SCOPES supports clinicians to deliver consistent, high-value post-exacerbation care aligned with QOF and local incentives. Since November 2025, >1,000 SCOPES optimise COPD reviews have been completed, improving the quality and consistency of care while supporting COPD optimisation.
SHIFT-AIR has strengthened system-wide collaboration and workforce capability. A regional primary care respiratory nurse education network, led by an ALUK Respiratory Champion, provides training and peer support. In parallel, an integrated COPD MDT connects healthcare professionals, enabling coordinated decision-making and earlier access to specialist advice.
Digital enablement through the myCOPD and myAsthma platforms has further enhanced patient support. Over 600 patients have been onboarded to myCOPD and >1000 to myAsthma, providing access to education, self-management tools and virtual pulmonary rehabilitation.
Community engagement has also been prioritised, including a “Neighbourhood Lung Health” event delivered with Southampton Football Club’s Senior Saints programme. Collectively, SHIFT-AIR has improved integration, strengthened respiratory care quality and shifted management toward community-based prevention and optimisation.
If you were to run the project again, what would you do differently?
If delivering this project again, I would place even greater emphasis on establishing strong data capture processes from the outset. Robust and consistent coding within primary care templates is essential to accurately measure impact, demonstrate outcomes and maintain engagement from clinical teams. Building these requirements into digital templates early would support more reliable evaluation and reporting.I would also ensure that key operational and digital stakeholders are involved from the very beginning of the project. Engaging primary care administrative leads and digital transformation teams early helps ensure that system changes, reporting mechanisms and workflow integration are designed effectively and implemented smoothly.
Finally, I would continue to prioritise meaningful stakeholder engagement with clinicians, but start this earlier and maintain it throughout delivery. Creating dedicated opportunities for clinicians to connect, discuss the project and share learning proved extremely valuable. Events that allowed time for networking and informal discussion, alongside clear explanation of the project’s purpose and benefits, helped build trust and enthusiasm. Embedding these engagement opportunities as a core part of the programme from the outset would further strengthen collaboration and support sustained implementation.
Advice you would have for others undertaking the same type of project.
For others undertaking a similar project, my key advice would be to focus on three areas from the outset: data, people and engagement.First, prioritise robust data capture, coding and information governance processes. Reliable data is essential to demonstrate impact, evaluate outcomes and sustain momentum across teams. Ensure that clinical templates and digital systems are designed to capture the right information consistently, and work closely with digital and data teams early to build reporting mechanisms that make it easy to monitor progress. Ensuring that appropriate information governance processes are in place from the beginning will support safe and compliant data sharing across organisations.
Second, involve the right people from the start. Projects that span multiple organisations and care settings rely heavily on operational support. Engaging primary care administrative leads, digital transformation teams and practice managers early will help ensure workflows are practical, system changes are implemented effectively and the project can be embedded into routine practice rather than added as an extra burden.
Finally, invest time in meaningful stakeholder engagement. Clinician buy-in is critical for successful implementation, particularly when introducing new pathways or tools. Providing opportunities for clinicians to understand the purpose of the project, share experiences and build relationships can make a significant difference. In our experience, dedicated engagement events that included time for discussion and networking were particularly valuable in building enthusiasm and collaboration.
Overall, maintaining clear communication, demonstrating early wins through data, and creating opportunities for shared learning across teams can help build momentum and support sustainable system change.