A targeted programme in North East and North Cumbria is helping people with chronic obstructive pulmonary disease (COPD) stay healthier for longer, improve their confidence in managing their condition and reduce the need for urgent and emergency care.

The OPTIMISE COPD programme was developed to identify patients most at risk of worsening symptoms and provide them with proactive support before they reach crisis point. Delivered through primary care, the programme moves away from a reactive approach and instead focuses on prevention, early intervention and personalised care.

During the pilot, 159 practices across North East and North Cumbria reviewed 1,936 patients identified as being at high risk of COPD exacerbations from a wider eligible population of more than 12,000 people. A COPD exacerbation (sometimes called a flare-up) is a sudden worsening of a person’s COPD symptoms beyond their normal day-to-day variation.

Finding and supporting those most at risk

Traditionally, many patients are invited for an annual COPD review around their birthday. However, this may not coincide with periods when they are most at risk of becoming unwell.

To address this, the programme used data and clinical searches to identify patients who were experiencing frequent exacerbations or whose treatment options may not have been fully explored. These patients were then invited for a comprehensive review.

Claire Adams

Describing the benefits of risk stratification tools, Claire Adams, Respiratory Programme Lead at North East and North Cumbria Integrated Care Board (ICB) explained:

“Taking a stratification approach is really important. If you know who your highest-risk patients are and bring them forward first, there’s an opportunity to intervene earlier and prevent deterioration.”

Patients attending a review received a holistic assessment covering medication, inhaler technique, symptom control, exacerbation history, vaccinations and wider support needs. They were also connected with services such as pulmonary rehabilitation, smoking cessation support and community respiratory teams where appropriate.

Putting patients at the centre

Patient engagement was a key part of the programme. Rather than focusing solely on clinical treatment, reviews were designed to help people understand their condition, recognise early warning signs and feel more confident managing their symptoms day-to-day.

Patients were supported with personalised self-management plans, information about available community resources and access to digital tools such as MyCOPD. Clinicians also discussed practical steps patients could take to stay well and what action to take if their symptoms worsened.

The programme generated substantial patient-focused interventions, including:

• 712 personalised self-management plans
• 433 rescue packs to support early treatment of exacerbations
• 628 medication optimisations
• 1,189 breathlessness assessments.

Reflecting on the figures, Claire said:

“Our patient feedback showed people felt more informed about COPD, better able to recognise deterioration and more confident managing their condition independently.”

The evaluation found the programme acted not just as a clinical review process, but also as a patient activation intervention, helping people take greater control of their health.

This was particularly important because almost 30% of patients lived alone and nearly half lived in some of the most deprived communities in the region, placing them at greater risk of poor health outcomes and hospital admission.

Reducing pressure on urgent and emergency care

The programme delivered improvements for patients alongside significant reductions in the use of urgent and emergency services.

Compared with a similar group of patients who did not receive an OPTIMISE review, those who took part experienced:

• 65% fewer urgent and emergency care contacts
• 76% fewer NHS 111 respiratory contacts
• 89% fewer 999 respiratory calls
• 53% fewer A&E attendances
• 58% fewer non-elective respiratory admissions
• 68% fewer respiratory bed days.

Claire added:

“A 68% reduction in bed days is just phenomenal. We saw very similar improvements to programmes delivered by specialist respiratory teams, but this was particularly meaningful as it was delivered through primary care.”

The evaluation also estimated savings of around £700,000 across the patient cohort reviewed during the pilot period.

Building clinician confidence

Alongside better outcomes for patients, clinicians reported increased confidence in managing COPD

The programme team developed and recorded training sessions, shared best practice across practices and provided access to specialist respiratory Advice and Guidance services to support clinicians managing complex cases. Clinical searches and a structured review framework helped standardise delivery, while evaluation findings are informing future plans to further develop workforce capability.

Claire described the educational aspects of the programme as follows:

“To deliver this new way of working, primary care needs to be upskilled. When we think about neighbourhood health and increasingly complex patients, investing in education and skill sharing is essential to making approaches like OPTIMISE sustainable.”

Tackling health inequalities to deliver care closer to home

The future development of the programme will focus on tackling health inequalities more effectively, ensuring all patients can benefit from the same level of support through the service.

Claire added:

Our current service is great for the patients who can make it into these reviews, but we also need to make sure our housebound patients and care home residents receive the same quality of COPD care.”

Once available to even more patients, the OPTIMISE programme will continue to demonstrate how identifying people with COPD early, engaging them in their own care and providing timely, personalised support can help them stay well, improve their quality of life and receive more care closer to home.