Forty high-risk people with COPD given help to address wider determinants through PHM

Case study summary

Forty people with chronic obstructive pulmonary disease (COPD) were given help from a health and wellbeing coach or social prescriber to improve control over their condition by pinpointing two issues which ‘mattered most to them’.

The Proactive Care Team, at Holderness Health Primary Care Network, worked on the project as part of the national Population Health Management (PHM) Development Programme.

Note: Some sections of this case study refer to clinical commissioning groups (CCGs). On 1st July 2022, integrated care systems (ICSs) took over statutory commissioning responsibilities in England, and CCGs were closed down.


ICS: Humber Coast and Vale (HCV) integrated care system (ICS) and Holderness Health Primary Care Network – Population size: 36,000

What was the aim?

They aimed to improve patient health and well-being in this group and reduce pressure on the health and care system by addressing the wider social determinants of health such as debt, weight management and stopping smoking. (Read a seven minute version of this case study at the PHM Academy).

What was the solution

The PHM Development Programme helps integrated care systems – like this one in Humber, Coast and Vale – understand and predict future health and care needs, reduce health inequalities and make better use of resources.

By using linked and analysed datasets from community services, primary care and secondary care, the Holderness Health PCN searched for patients aged 48-64 with a diagnosis of COPD, hypertension and additional risk factors who were overdue a COPD review.

Data showed this cohort were often not using services until their condition exacerbated – meaning an increased cost to the system later on.

A cohort of 40 patients were identified who were in receipt of regular repeat prescriptions and many had multiple secondary care admissions.

They were contacted and offered a phone assessment with a health and wellbeing coach or social prescriber.

An assessment tool was developed through the PHM programme’s Action Learning Set, and baselines for each patient were established using the MRC Dyspnoea Scale and COPD Assessment Test (CAT).

Following the appointment, a multidisciplinary team including social prescribers, a health coach, care coordinators, other primary care staff and community services created a personalised approach to understand each individual’s physical, emotional, practical and living concerns and identify wider determinants to address.

The team worked with each patient to create a personalised care plan to ensure the best outcomes, and coordinate appropriate support and interventions.

What were the challenges

Holderness Health is a single practice PCN which covers a large geographical area with high levels of respiratory illness and mortality due to respiratory disease in coastal areas.

Heather Whitfield, head of projects and performance at the PCN, said: “Respiratory illness had been identified as a priority area for Holderness, where lung cancer and COPD cases are well above national averages. We were also aware of significant variation in the prevalence of smoking and the take-up of screening and vaccination programmes. CCG figures showed there is a high prescribing spend for respiratory illness, and we are an outlier for respiratory admissions.

“Through this project, we aimed to increase the uptake of reviews, reduce unnecessary appointments and GP activity, increase proactive care delivery, a more personalised system of care and improve quality of life for patients living with long-term conditions.

“To support this work, we had already directed some of our initial social prescribing budget towards areas of deprivation and recruited two full-time equivalent specialist respiratory advanced clinical practitioners. We hoped this project would provide an insight into how this new resource should be utilised”.

What were the results

In the one-hour appointment, every patient was supported to complete a holistic needs assessment based on what matters to them and identify two priority issues.

The PCN hoped this could help identify precursors to poor control of COPD – including non-medical causes but those who flagged for needs via clinical interventions were brought in for a respiratory review.

The assessment focused on social-economic triggers related to COPD.

72% of those who engaged with the project were living in areas of high deprivation and disclosed that their health had deteriorated in the last 12 months. Support with finances, losing weight and stopping smoking were the most common themes.

One patient said: “My COPD six-month review has given me a very positive experience that gives me a chance to discuss any concerns that I have – together with the opportunity to arrange any follow-ups that may be beneficial. I also feel that I’m not on my own and have a medical team that cares.”

Patients were reviewed at six months and will be reviewed again at 12 months to further reduce the need for clinical appointments. Data from the reviews completed so far show that 100% of patients had the same or an improved number of exacerbations, 75% had the same or improved MRC Dyspnoea Scale score, and 44% had the same or improved CAT score.

What were the learning points?

The team acknowledges that it has been challenging to get the patients to engage and take part in the reviews, and three have not yet had their six-month review completed.

It is also often difficult to know how well engagement went once patients have been referred or signposted to third parties, but the team is now asking about this in the six-month reviews and looking to adopt this communication point into their normal practice.

Heather added: “The pilot has been well received by those who have engaged with the initial consultation. The relationship between the health and wellbeing coach, social prescribing link worker and care coordinator provided a solid underpinning for patients on where and who were best to meet their disclosed social needs and referrals were made quickly.”

David Fitzsimons, Clinical Director, said: “The best part of this programme was working with different providers to design a new style of intervention. PCNs often struggle to consider how to best use their ARRS funding. However, I feel our intervention has shown how social prescribers and health coaches can assist with the QOF process and deliver a more personalised and effective model of care.”