In areas with the highest social deprivation, alongside practice staff, we reviewed the clinical record and diagnostics of people with a diagnosis of both chronic obstructive pulmonary disease (COPD) and asthma and confirmed diagnosis where possible. In the practice, we arranged missing diagnostics and delivered local OPTIMISE COPD or asthma reviews, with practice staff.
Submitter(s): Paul Walker
Submitted:
The publication of the latest NHS Long term Plan provides the framework for services to move towards a community healthcare approach. Multiagency events bringing together healthcare teams, charities, and government organisations that serve the local population in a holistic way can be a key contributor to achieving this goal.
Submitter(s): Luke Zubiena
Submitted:
Historically prescribing of rescue packs for patients with chronic obstructive pulmonary disease (COPD) within our practice has been on repeat prescription.
I could see the perils of putting rescue packs on repeat, overuse, poor prescribing practice and lack of follow up. Therefore a System of Practice was developed to improve patient care by prescribing effectively.
I could see the perils of putting rescue packs on repeat, overuse, poor prescribing practice and lack of follow up. Therefore a System of Practice was developed to improve patient care by prescribing effectively.
Submitter(s): Christine Ritchie
Submitted:
• A range of chronic obstructive pulmonary disease (COPD) risk stratification approaches were utilised to discuss 390 patients at virtual multidisciplinary team (MDTs) across East Birmingham and Solihull, supported through an Integrated Care Board (ICB)-wide community of practice forum.
• MDTs facilitated cross-sector collaboration and learning, however limited funding and administrative support impacted the opportunity risk-stratified care could provide.
• MDTs facilitated cross-sector collaboration and learning, however limited funding and administrative support impacted the opportunity risk-stratified care could provide.
Submitter(s): Lucy Boast
Submitted:
The pilot was a primary care led virtual ward model, but with support from the specialist community respiratory team and hospital respiratory services. It provides an example of integrated multidisciplinary working, providing services in the community with a focus on deprived areas with a high prevalence of respiratory disease.
Submitter(s): Kate Stonier
Submitted:
The Hastings chronic obstructive pulmonary disease (COPD) Health Inequalities Improvement Programme uses population health insight, integrated neighbourhood working, and pathway redesign to address severe respiratory inequalities. It strengthens primary–community–secondary care collaboration, improves earlier diagnosis and optimisation, and pilots targeted interventions to reduce variation in access, outcomes, and unplanned admissions.
Submitter(s): Lisa Sansom
Submitted:
This case study outlines the impact of an advanced respiratory diagnostics service in primary care. The service supports 22 GP practices across rural Armagh and Dungannon region, serving a population of approximately 80,000 in NI. The region ranks 208 out of 217 in the UK for respiratory admissions and mortality
Submitter(s): Melissa Traynor
Submitted:
The purpose of this project was to improve the satisfaction, adherence and efficacy of the pulmonary rehabilitation (PR) service, in a rural, isolated, coastal community by integrating patient and public feedback to the programme redesign.
Submitter(s): Naomi McKnight
Submitted:
The SHIFT-AIR programme aims to transform care for at-risk chronic obstructive pulmonary disease (COPD) and asthma populations in Southampton and Portsmouth. Funded by Health Innovation Network (HIN) - Respiratory Transformation Partnership (RTP) and delivered across 14 primary care sites covering 270,000 patients, it embeds proactive case-finding and rising-risk optimisation across integrated care pathways, strengthens third-sector partnerships, and expands digital self-management.
Submitter(s): Hannah Burke
Submitted:
Implementation of PGDs within chronic obstructive pulmonary disease (COPD) patients in South Manchester to improve “time to treatment”. Thus, reducing burden on primary care, emergency department visits and ensuring efficient use of the work force.
Submitter(s): Craig Pownall
Submitted:
In response to a requested from the Integrated Care Board (ICB) to help bolster winter resources for respiratory patients, an proactive approach was taken to unite the respiratory neighbourhood and make it accessible to all patients by organising multiple lung health fairs.
Submitter(s): Sally Merson
Submitted:
A Breathe Better Project which aims to:
1. Bring together patients with chronic obstructive pulmonary disease (COPD), carers, clinicians, voluntary and community groups
2. Use an asset-based community approach including third sector groups
3. Embed it in the system so that if recurrent funding isn’t available, it would still be sustainable
4. Improve well-being, reduce anxiety, social isolation and increase activity
5. Move focus from medicines and tests to helping people with living with and managing their condition
1. Bring together patients with chronic obstructive pulmonary disease (COPD), carers, clinicians, voluntary and community groups
2. Use an asset-based community approach including third sector groups
3. Embed it in the system so that if recurrent funding isn’t available, it would still be sustainable
4. Improve well-being, reduce anxiety, social isolation and increase activity
5. Move focus from medicines and tests to helping people with living with and managing their condition
Submitter(s): Sue Mason
Submitted:
The provision of a Community Lung Health Day in Lambeth & Southwark, carried out to support patients with respiratory disease and improving their lung health and their Vital 5 (Alcohol, Healthy Weight, Hypertension, Mental Health and Tobacco Dependency), through addressing social determinants of health. Other aims included increasing enrolment to pulmonary rehabilitation (PR) and improving integration of the respiratory team and voluntary, community and social enterprise (VCSE) organisations.
Submitter(s): Alicia Piwko
Submitted:
Using a local Breathe In Sing Out group to improve the symptoms and impact experienced by people with long-term respiratory disease.
Improvements reported in the ability to manage conditions, less need to use medication and inhalers and increased motivation and social engagement. NHS data showed reduction in both hospital admission and ED attendance.
Improvements reported in the ability to manage conditions, less need to use medication and inhalers and increased motivation and social engagement. NHS data showed reduction in both hospital admission and ED attendance.
Submitter(s): Ruth Melhuish
Submitted:
A project to proactively manage people at risk of developing, or who have a diagnosis of respiratory disease, via the provision of a neighbourhood place based holistic approach to care. The service supports patients with respiratory diseases including COPD.
Submitter(s): Deepak Subramanian
Submitted:
Working in partnership with Health and Care Innovations (HCI) the Torbay and South Devon NHS Foundation Trust (TSDFT) respiratory team have co-designed and deployed resources on the multi-condition CONNECTPlus app to support COPD self-management and pulmonary rehabilitation (PR). The app utilises a "For, From, About" model and ensure a comprehensive approach to patient management and access to information (for both healthcare professionals and patients).
Submitter(s): Matt Halkes
Submitted:
Breathlessness is a common symptom heralding serious underlying cardiopulmonary disease, and early and accurate diagnosis is essential to reduce emergency healthcare use and improved patient outcome. In Merseyside, an initiative launched by Everton Football Club (Everton in the Community) seeks to address this challenge by the implementing a ‘Beat Breathlessness Clinic’ based on the NHS England (NHSE) Adult Breathlessness pathway.
Submitter(s): Biswajit Chakrabarti
Submitted:
Identifying rising risk COPD patients in 3 local primary care network (PCN) areas in order to improve patient care and outcomes. Improvements required and achieved include increased multidisciplinary working, better clinical pathways and coding, increased pulmonary rehabilitation (PR) completion and self-management and successfully addressing social and environmental factors associated with poorer outcomes.
Submitter(s): Rachel Williams
Submitted:
The NNHIP West Leicestershire COPD Programme aims to improve integrated care and quality of life for patients with COPD by participating in Wave 1 of the National Neighbourhood Health Implementation Programme (NNHIP). Key project outcomes looking to be achieved include development and implementation of personalised care plans for COPD patients and establishing consistent multidisciplinary team (MDT) working across all participating federation areas.
Submitter(s): Leslie Borrill
Submitted:
Introducing a dedicated link worker (social prescriber) within a pulmonary rehabilitation (PR) service to address wider determinants of health (health inequalities, poverty, housing, social isolation etc) which impact patient engagement, adherence and completion rates of PR.
(Submitted by Michelle Maguire, on behalf of the Imperial Community Respiratory Team)
(Submitted by Michelle Maguire, on behalf of the Imperial Community Respiratory Team)
Submitter(s): Michelle Maguire
Submitted:
A project conducted to co-produce a data led approach to respiratory care; that proactively manages patient care and leverages all available resources (positively impacting patient health, reducing utilisation costs and patient admissions). Work was conducted in an area with very high social deprivation and smoking rates, and where 56+ different languages are spoken.
Submitter(s): Sonia Silk
Submitted:
The establishment of a Living Well Service (LWS) to tackle the under recognition of Breathing Pattern Disorder, particularly complex breathlessness. The LWS provided thorough bio-psycho-social assessment, the consideration of differential diagnosis and any outstanding investigations, to ensure any co-morbidities were managed. Key features included co-production of care through goal setting and provision of a tailored self-management program, as well as a specific intervention group for complex breathlessness.
Submitter(s): Lois Botham
Submitted:
Introducing FebriDx (Lumos Diagnostics) for c-reactive protein (CRP)/viral biomarker testing in COPD patients. Introduction was to improve patient care, outcomes and reduce costs associated with admission/readmission to hospital, travel, GP attendance and medications.
Submitter(s): Elaine Sutherland
Submitted:
Comprehensive assessment of patients with COPD post-exacerbation frequently identifies the need for exercise, however due to significant symptom burden, high prevalence of malnutrition, and frailty and falls risk, an alternative to the current home exercise programme (HEP) offer was required. The objective was to diversify home rehabilitation options to improve equity and access for patients with COPD to optimise outcomes and reduce exacerbation risk.
Submitter(s): Elaine Sutherland
Submitted:
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