Using Population Health Management to target COPD support for low, medium and high risk groups in Dorset

Case study summary

Nearly 3,000 people in Dorset with Chronic Obstructive Pulmonary Disease (COPD) at risk of degenerating health were helped to manage their condition and improve their wellbeing using a Population Health Management approach.

A mix of analysts, nurses, social prescribers, GPs, a consultant, a patient group and local authority colleagues in Weymouth and Portland Primary Care Network (PCN) worked together to identify and support 2,390 low risk, 224 medium risk and 273 high risk patients with COPD.

The groups were given fresh access to health apps, social prescribers, group consultations and carousel clinics.


Weymouth and Portland PCN – Dorset

Population size: 76,000

The aim

Weymouth and Portland had an existing focus on COPD and respiratory issues and they aimed to use the opportunity of being part of the national PHM Development Programme to understand the scale of issues and complexity across their population. To keep people well, they wanted to work with patients to develop more proactive care options for people based on what matters to them.

The solution

To assess the risk of people with long-term conditions, data was collected through health APP, Medical Research Committee (MRC) scores and patient activation measures (PAM).

The data specifically highlighted that they needed to focus resources on people living in the highest deprivation quintile. It also showed that people living in those areas have 10 fewer years of good health than others living in affluent parts of Dorset. People with COPD living in the most deprived areas are three times more likely to smoke, which impacts their long-term health outcomes.

Workshops to design care and support for each risk cohort led to a range of interventions. Moderate and high-risk patients were given access to GPs, specialists and health coaches through carousel clinics, they also had specialist nurse reviews to reduce exacerbations and ensure they had anticipatory care plans and rescue medication available.

Low risk patients were offered group consultations and digital support tools to improve their self-care and disease awareness. Dorset had invested in licences for the my mhealth apps and social prescribers and health coaches supported patients to access them. This was an effective care option for a large low-need population when used alongside group consultation, and ensured clinical time was focused on those in the higher risk groups with less well controlled disease.


We want to ensure we can monitor impact effectively and this will be on-going. Once people have received the intervention, they are asked consent for monitoring outcomes. Clinical staff ask for patient consent to use their data for continuous improvement. To support outcomes monitoring, PCNs are looking to supplement the patient record data with patient surveys and activation measures.


Doreen was identified as someone who would benefit from a self-care approach.  She said: “It was really helpful to access education on my illness, lots of lovely support and loved the exercises, I found them helpful am still doing them and will continue to do so, definite help, thank you.”

GP Dr Simone Yule from the Blackmore Vale Practice said: “This is about using the PHM approach to deliver our core work – the Quality Outcomes Framework (QOF), Directed Enhanced Service (DES) and use of the Additional Roles Reimbursement Scheme. It’s helping GPs, nurses and hospital clinicians work with partners to address people’s problems which are not medical but have a huge impact on their health. This helps us use resources which are already there, spread the workload and relieve the pressure on general practice.”

Learning points

The integrated approach to long term condition care brought clinicians together from different parts of the system, breaking down the organisational siloed approach to care.

Workforce satisfaction was high as staff were involved in development of the service from the beginning. Headspace gave individuals time, to work together as a team working across boundaries and the pilot started the wider conversation about partnership working.

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