Improving COPD care: what we’re learning from neighbourhood teams

Many of the people I see with Chronic Obstructive Pulmonary Disorder (COPD) have lived with breathlessness and exacerbations for years before receiving the right support. Some are first identified during a hospital admission. Others have attended routine reviews but missed opportunities for pulmonary rehabilitation, optimised inhaler treatment, specialist input or support to stop smoking. Some have been prescribed repeated rescue packs without a review of why their exacerbations are happening.

It is clear that, for many people, the current model of COPD care is not working well enough.

The Respiratory Transformation Partnership (RTP) is exploring how we can shift care upstream: diagnosing COPD earlier, getting the fundamentals of care right, identifying people at rising risk of deterioration and providing specialist support before people reach crisis.

What does neighbourhood working mean?

Neighbourhood working means organising care around the needs of a local population, rather than around individual organisations.

Primary care, community services, hospital specialists, pharmacists, voluntary-sector organisations and local authorities work together around a shared population and shared objectives.

For COPD, this matters because no single organisation has all the data, expertise, relationships or resources needed to improve outcomes.

Population data can help identify people who may have undiagnosed COPD or whose risk is increasing. Quality-assured diagnostics can bring testing closer to home, while rapid access to specialist advice can support people with diagnostic uncertainty or complex disease.

And because health is influenced by factors such as housing, finances, transport, social isolation and trust, working with voluntary and community partners can help address needs that sit beyond healthcare.

The aim is simple: build the team around the patient, rather than expecting the patient to navigate the system.

Nine areas, one shared question

Between October 2025 and March 2026, nine health systems across England received £2.61 million through NHS England’s Pathway Transformation Fund as part of the RTP.

The COPD programme had two connected strands:

Earlier diagnosis – improving access to quality-assured spirometry, training staff and using primary care data to identify people who may have undiagnosed COPD.

OPTIMISE – a structured approach for people with diagnosed COPD who are at rising risk of deterioration:

• Find people at increased risk of exacerbation.
• Review their treatment, clinical needs and wider circumstances.
• Empower them with knowledge, support and a personalised care plan.

Respond — provide a clear route back into care and respond quickly when symptoms worsen or an exacerbation occurs.

Together, these approaches create a more proactive pathway: find disease earlier, get the diagnosis right, identify rising risk and intervene before crisis.

Different neighbourhoods, the same principles

There was deliberately no single delivery model. Each area adapted its approach to its population, workforce and existing services.

Cornwall brought clinical and voluntary-sector teams together through “Super Saturday” clinics. Southampton developed a network of respiratory champions to strengthen reviews in primary care. Manchester brought consultant respiratory expertise into community settings. Hull linked diagnosis with lung cancer screening and used multidisciplinary teams (MDTs)to support primary care. North West London developed 25 community respiratory diagnostic hubs.

In Liverpool, specialists worked with primary care to improve registers and review complex patients, while patients could be connected with Citizens Advice for support with finances and housing. Sherwood used secondary-care physiologists and specialist MDT working to improve diagnostics and optimise patients across three Primary Care Networks (PCNs).

The models looked different, but the principle was consistent: bring the right people and expertise together around a defined population and problem.

What did the first six months deliver?

Across the nine areas:

• More than 4,100 breathing tests were carried out
• More than 2,200 COPD diagnoses were confirmed
• 5,029 people were identified as suitable for an OPTIMISE review
• 1,440 OPTIMISE reviews were completed
• Nine in ten completed reviews resulted in a personal care plan

There were important local improvements too. In Mid Yorkshire, the spirometry waiting list fell by more than a third.

Interim evaluation, October 2025–March 2026. Some site data is incomplete.

What did the review process reveal?

The OPTIMISE reviews demonstrated the value of actively looking for rising exacerbation risk, rather than waiting for deterioration to become a crisis.

People identified through population searches often had multiple opportunities to improve their care: treatment that could be optimised, poor inhaler technique or adherence, unmet pulmonary rehabilitation or vaccination needs, continued smoking, and wider physical, psychological or social needs.

The review therefore became much more than a medication check. It provided an opportunity to understand what was driving that individual’s risk — and what could be changed to prevent their next exacerbation or hospital admission.

There was important system learning too. Searching for people who appear to be at risk is relatively straightforward; making sure we have found the right people, and having the capacity to act, is harder. In some areas, considerable work was needed to clean COPD registers and confirm that those identified actually had a diagnosis of COPD.

Population searches therefore need to be linked to a workforce with the skills and time to undertake comprehensive reviews, rapid access to specialist advice when needed, and services that can respond to the problems identified.

We also learnt that not every patient needs to be brought into a face-to-face specialist clinic. Virtual notes review can enable rapid changes in care while identifying those who would benefit most from further assessment. In Sherwood, for example, around 50% of cases could be optimised remotely by specialist nurses, allowing face-to-face capacity to be focused on those who needed it most.

Taken together, the programme demonstrated that COPD care can be reorganised around a population: finding people who are missing from care, bringing diagnostics and specialist expertise closer to home, identifying rising risk earlier, and intervening before people reach crisis.

That is neighbourhood working in practice.

What did patients tell us?

The numbers tell us what the programme delivered. Patient experience tells us something equally important: what different care actually felt like.

One patient described the difference that simply having enough time made:

I had a chance to stay! Usually you’re in and out… It wasn’t rushed. They were actually looking at my problems and trying to sort it out.”

Another described a much more profound change:

I’ve told so many people… it is just the most brilliant thing that has ever happened in terms of my health. It wasn’t just seeing somebody, because I’ve done that plenty of times over the years, it’s actually seeing this team and the resultant advice and help… When I went to see my doctor the last time he couldn’t believe it. He said, ‘Have you had a lung transplant?’”

Feedback like this was powerful for the teams involved. Patients were not simply describing better access to a service. They were describing a different experience of care: having enough time, seeing people with the right expertise, being listened to, and having different aspects of their care considered together rather than in isolation.

That matters because this is exactly what neighbourhood working should achieve. Success is not simply moving a clinic out of hospital or delivering more appointments. It is whether bringing teams together around a patient results in care that is more joined-up, more personalised and more useful to them.

Not every patient reported an improvement. One person, for example, told us that the additional support had made no difference to their breathlessness. That feedback matters too. COPD is a complex condition, and better organised care cannot remove every symptom or meet every need.

But across more than 680 pieces of patient feedback, a consistent pattern emerged. People particularly valued having time, access to expertise, being listened to and being involved in decisions about their care.

For me, perhaps the most powerful message is a simple one: patients noticed the difference when services stopped organising care around organisational boundaries and started organising it around them.

What does it take to make neighbourhood working succeed?

The programme has highlighted several practical requirements:

• Time and capacity matter
• Good data is essential
• The intensity of the intervention matters
• Engagement cannot be assumed
• Local context matters

If neighbourhood models are to become routine care rather than short-term projects, these enabling conditions need to be designed in from the start.

What happens next?

This work is not finished. The next phase is about embedding what we have learnt into pathways of care — starting good COPD care and patient education from the point of diagnosis, strengthening and sharing the evidence, and making it easier for neighbourhoods to put the learning into practice.

We need better coding, better and more accessible data, and a clearer understanding of the resources required. That includes an honest comparison with the time and cost of the annual reviews we already provide. Our final report, due in December 2026, will include linked patient outcome data and should allow us to understand much more about impact, outcomes and where the greatest value lies.

But we already know enough to be confident about the direction of travel.

Respiratory expertise needs to be part of neighbourhood working, not simply something accessed at the end of a referral pathway. Respiratory champions supported by specialists within neighbourhoods can provide the local leadership, capability and connections that help make this possible.

Voluntary and community sector partners also need to be visible, connected and part of the team from the outset, rather than brought in as an afterthought. They can build trust, address wider needs and reach people whom traditional healthcare services may struggle to engage.

The task now is not to impose a single model everywhere. It is to define a core framework and principles that should be consistent — with agreed outcomes against which we can measure success — while giving neighbourhoods the freedom to organise delivery around their own populations, workforce and local assets.

Ultimately, this is about creating a pathway that works better for people with COPD: finding disease earlier, getting the diagnosis right, delivering the fundamentals of care well, recognising rising risk and providing timely access to specialist expertise and advanced interventions when they are needed.

Neighbourhood working gives us the opportunity to do that differently — to work together, with patients’ needs at the heart of what we do.

That has to be a good thing.