Abstract

Description

People living with chronic obstructive pulmonary disease (COPD) in Scotland experience gaps in care, including delayed diagnosis and limited access to self-management support (1). Historically, collaboration between the Midlothian Community Respiratory Team (MCRT) and Chest Heart & Stroke Scotland (CHSS) (2) has been limited, contributing to suboptimal uptake of services, particularly in underserved communities.

Patient and Public Involvement (PPI) informed pathway development and service design throughout the project, ensuring a person-centred approach.

This poster outlines a collaborative quality improvement (QI) project to strengthen COPD referral pathways between MCRT and CHSS, improve access to CHSS-supported self-management, enhance integration between respiratory care and third sector support, and strengthen partnership working.

Methodology

Using a model of improvement and iterative Plan–Do–Study–Act (PDSA) cycles (3), quantitative referral data and qualitative feedback from patients and staff was collected between November 2024 and December 2025.

The intervention included staff workshops, pathway development, and access to CHSS services, including a novel validated Stanford 6-week supported self-management (SSM) programme.

A 30-member PPI group informed pathway development, identifying barriers and facilitators to engagement and refining referral processes to improve uptake.

Evaluation focused on activity, engagement, equity, and safety.

Aims/Objectives

Improve COPD care by co-designing a strengthened MCRT–CHSS referral pathway
Increase referrals from 9 (2024) to 100 over 12 months and improve uptake of self-management interventions
Enhance NHS–third sector collaboration and integration of COPD care
Assess uptake across SIMD quintiles, focusing on SIMD 1–2

This project aligns with realistic medicine principles (4), demonstrating co-designed, patient-centred, and transferable approaches to integrated COPD care.

Results/Outcomes

102 patients accepted referrals, accessing 185 CHSS services
45% were from underserved SIMD 1–2 communities
40 patients enrolled in the Stanford supported self-management programme
Barriers included referral approach, access needs, and limited information
Joint MCRT–CHSS workshops identified 10 service improvements
Early outcomes indicate positive patient benefit
Full datasets will be presented in the poster

Conclusions

This project demonstrates that co-designed NHS–third sector pathways can deliver sustainable, cost-effective, and equitable COPD care, improve access to self-management interventions, and generate learning on partnership working and service integration to support wider adoption and scale-up.