Abstract

Background:

Patients with COPD in Scotland can experience gaps in care, including delayed diagnosis and limited access to optimal care. Despite availability, interactive working between third Sector services such as Chest Heart Stroke Scotland (CHSS) and the community respiratory team in Midlothian (MCRT) has historically been low, limiting usage of valued services for patients, particularly in underserved areas.


Objectives:
To improve access to self-management support by strengthening the MCRT–CHSS referral pathway, increasing referrals from 9 to 100 over 12 months, and enhancing integration and collaboration.


Methods:
A QI approach using a Theory of Change and iterative PDSA cycles was used. We integrated quantitative data with qualitative feedback from staff and patients, identifying barriers, testing changes, and evaluating activity, engagement, equity, and safety.


Results:

102 patients accepted referrals (45% SIMD 2), accessed 185 services (1.81 per patient) with 40 accepting a new 6 week supported self-management (SSM) group.
Barriers to accessing CHSS services included the method of offer, referrer familiarity, limited written information, digital/physical constraints, and need for carer support.
Workshops strengthened NHS–CHSS relationships and role clarity, identifying 10 process improvements with 4 implemented and ongoing work continuing.
Referral numbers and staff engagement was maintained despite contextual pressures such as staff vacancies and clinical pressures.
Early SSM data suggests good outcomes for patients. Fully evaluated datasets would be presented at the conference.


Conclusion:

Aligned to Realistic Medicine, collaborated and cocreated pathways involving NHS and Third sectors can support sustainable, cost-effective and equitable COPD care.