Respiratory Improvement – A data led journey to a collaborative change

Project overview, including who was involved in the project
The Respiratory Improvement project was delivered collaboratively by ESHT’s RESPS Team and Bexhill PCN and aimed to proactively manage high risk respiratory patients through digitally enabled remote monitoring. The partnership targeted patients with COPD, bronchiectasis, and interstitial lung disease (ILD), identified using the University College London (UCL) Proactive Framework and PCN multidisciplinary review.
Patients were onboarded to Doccla, a virtual care platform enabling real-time monitoring via smart devices, with clinical oversight provided by the RESPS Team. Observation parameters were set to trigger alerts, prompting patients to contact the RESPS duty line for assessment and escalation if required to virtual wards or acute care.
The project also implemented a two-part clinical model:
Part 1: RESPS-led onboarding, monitoring and clinical assessment.
Part 2: GP respiratory reviews supported by RESPS-led multidisciplinary meetings (MDMs), involving consultants, specialist clinicians, and hospice partners to discuss complex cases.
A patient experience survey demonstrated high acceptability and confidence in the system, with 100% of respondents recommending the service and 70% describing it as very easy to use.
The project provides a data-driven proof of concept for integrated, digitally supported respiratory care across community and acute systems, informing future expansion into neighbouring PCNs and alignment with the incoming Sussex Remote Monitoring Hub.
Project outcomes/impact
The Doccla pilot delivered measurable improvements across patient outcomes, service utilisation, and system efficiency. Accident and emergency (A&E) attendances reduced by 50%, while half of monitored patients required no GP contact, demonstrating effective early intervention and a shift from reactive to proactive care. Increased RESPS interactions reflect more appropriate clinical engagement in the community.
Financial benefits were also identified, largely driven fewer admissions, reduced length of stay, and lower community contact intensity.
The patient survey further evidenced impact, with all respondents feeling well supported and confident in their escalation pathway.
Clinically, the project strengthened integrated working between RESPS, PCN multidisciplinary teams (MDTs), and consultants. Outputs highlights reduced emergency demand, better management of exacerbations, and more targeted clinical oversight, supporting improved population respiratory health and operational productivity.
The learning has informed next step planning, including phased rollout to additional PCNs, workforce upskilling, and collaboration with regional partners (Hastings PCN, NHS Confederation). These findings strongly evidence the value of expanding remote respiratory monitoring across East Sussex.
If you were to run the project again, what would you do differently?
We would also refine data collection processes at baseline to strengthen real-time evaluation of clinical outcomes and cost impact.
Advice you would have for others undertaking the same type of project.
Ensure strong early collaboration between primary and secondary care to build shared ownership and clear governance. Invest time in robust patient selection criteria and simple onboarding processes to support engagement and uptake. Prioritise clear escalation pathways so staff and patients understand how and when to respond to alerts. Build in continuous feedback from patients and clinicians to refine the model in real time. Finally, use data from the outset to demonstrate impact, support sustainability, and secure wider system buy-in for scaling the model.