Neighbourhood COPD Risk Stratification Project - PCN Collaboration

[Disease management Medical and Associated services - Respiratory medicine] Advances in COPD treatment and management provide an opportunity to improve outcomes through earlier identification and intervention using a risk-based approach to care, focused on identifying patients at greatest risk and providing timely access to specialist support and treatment.

This project aims to develop and implement a specialist-led, integrated neighbourhood model of care for people living with COPD across Hull and East Yorkshire. Using digital risk stratification and multidisciplinary specialist review, the project will proactively identify high-risk patients, support preventative intervention, and improve access to specialist care within community settings, in line with NHS priorities to shift care from hospitals to communities and from treatment to prevention.

Primary Care Networks (PCNs) will be appointed to act as delivery partners in the implementation and evaluation of this model. Working alongside specialist respiratory teams, based at Hull University Teaching Hospital, participating PCNs will support the identification, review and management of high-risk patients, while helping to build capability within primary care. The project will test the feasibility and impact of this neighbourhood-based approach and generate learning to inform future commissioning decisions and potential wider adoption across the Humber region and beyond.

A suitable Provider shall be a Primary Care Network (PCN) or primary care organisation serving a registered population of at least 30,000 patients, demonstrating the scale, infrastructure, and capability required to deliver high-quality, sustainable respiratory services within populations where the recorded QOF COPD prevalence exceeds 2.5%, demonstrating experience in meeting the needs of communities with a significant burden of respiratory disease.

Please refer to the Services Specifications for full details.