Optimising Chronic Obstructive Pulmonary Disease (COPD) management for those at greatest risk – COPD Winter Planning
COPD Winter Planning aims to improve care for people with chronic respiratory condition, during winter months and beyond.
Impact
The programme has been co-designed with patients and clinicians across four test sites, within the South West and beyond, with benefits including:
- Increased access to evidence-based treatments to 298 patients at greatest risk of exacerbating.
- Increased access to community-based support to address the wider determinants of health.
- Increased referrals to pulmonary rehabilitation, smoking cessation and self-management interventions.
- Avoiding patient harm by reducing the risk of exacerbations through early intervention and self-management.
- Reduction in respiratory-related GP visits and hospital admissions.
- Reduced patient travel for appointments supporting lower carbon emissions.
- Cost savings to the health system through reduction in healthcare utilisation.
- Increased staff capability through training and tools.
Project summary
Health Innovation South West continues to be the lead delivery partner on the Lung Health @home programme, which has been running since 2021 and aims to improve health outcomes for people with a respiratory condition. This year has seen the publication of our case study report detailing the impact of the national test sites, along with two case studies in the South West region.
In 2024/2025, the focus of the programme has been on COPD Winter Planning which targets the seasonal vulnerability of people with COPD. The approach involves identifying rising-risk patients using Population Health Management data, optimising their care through a holistic review (OPTIMISE), supporting self-management with remote monitoring and education, and strengthening service access to those experiencing winter respiratory challenges.
Health Innovation South West has supported development of the approach, and is leading the evaluation design, analysis and synthesis. The evaluation is due to be completed in June 2025.
Rationale
The COPD Winter Planning approach was developed in response to regional and national evidence highlighting the need for greater support for people living with respiratory conditions, particularly during winters months when more common and severe.
COPD rates in the South West region exceed the national average: Devon 2.3%, Cornwall 2.4% and Somerset 2.73%, compared with the England average of 1.9%. Access to spirometry, a lung function test and key diagnostic tool, is limited or non-existent in some areas and where available, patients often travel long distances for testing. Referral rates for Pulmonary Rehabilitation are significantly lower across the South West compared to the England average.
A proactive, data-driven approach focused on community-based prevention and self-management was needed.
Key stakeholders
- Health Innovation South West are the lead delivery partner.
- NHS England Personalised Care and Community Services Team & Cardiovascular and Respiratory (CVD-R) Programme Team are responsible for programme leadership and strategic oversight.
- Four national test sites for the COPD Winter Planning Approach:
- Hull University Teaching Hospitals NHS Trust
- University Hospital Southampton NHS Foundation Trust
- King’s College Hospital and Guy’s & St Thomas’ NHS Foundation Trust
- Cornwall Partnership NHS Foundation Trust
- Swart Evaluation Ltd
- Peninsula Technology Assessment Group (PenTag), University of Exeter
Next steps
The national evaluation of COPD Winter Planning, including health economic analysis and learning, is due to be completed in June 2025.
Health Innovation South West will continue to provide support for scaling and spreading the approach across regions, as well as ongoing refinement of resources, tools, and training to embed COPD Winter Planning into year-round respiratory care pathways.
Health Innovation South West has continued to be an integral delivery partner for Lung Health @home, supporting the development, testing and evaluation of new pathways to support people with respiratory conditions to better manage their health at home. This year, the work has focused on working with four test sites to evaluate an approach to identify and optimise care for people with COPD at high risk of exacerbating over winter.
Isabel Queenan - Senior Programme Manager, NHS England
