COPD Winter Readiness

Chronic Obstructive Pulmonary Disease (COPD) exacerbations have a considerable impact on healthcare costs and mortality rates, with over one-fifth of patients hospitalised for a COPD exacerbation for the first time and subsequent mortality within one year of discharge. Exacerbations of COPD account for one in every eight admissions, increasing by around 13% each year and are the second largest cause of Emergency Department (ED) admissions in the UK.

COPD exacerbation's significantly rise during colder months, with approximately 50% increased hospital admissions for COPD patients in winter compared to summer months. For every degree drop in temperature below 5 °C, there is a 10.5% increase in primary care respiratory consultations and a 0.8% increase in respiratory admissions.

The cost of respiratory care for COPD across Norfolk and Waveney is estimated to increase by 11% over the next ten years. Respiratory diseases are more prevalent in areas of social deprivation due to factors such as higher smoking rates, exposure to air pollution, and poorer housing conditions.

These health inequalities lead to worse health outcomes and a widening gap between the rich and poor in respiratory disease mortality. Early intervention and improving the treatment of people with COPD is part of ICB's Prevention Programme.

This project seeks to utilise public health management data, mitigate health inequalities and improve accessibility through risk stratification and review utilisation of digital technology for patients with moderate to severe COPD, who would benefit from proactive patient identification, engagement and medicines optimisation The project can only be delivered through to utilisation of LungHealth COPD software provided by NSHI. The software is a proven product, and carries full NHS digital accreditation (ORCHA and DTAC) and is listed on the LPP NHS Framework.

The Quality Outcomes Framework lists the prevalence of COPD in Norfolk and Waveney at 2.3%, (England average 1.9%) (QOF, 2021-22). N&W ICB serve a combined population of 24,429 Chronic Obstructive Pulmonary Disease (COPD) patients.

This project supports the N&W ICS five-year joint forward plan (N&WICS, 2025) and the development of integrated care. Four key themes: Driving integration; Prioritising prevention; Addressing inequalities; Enabling resilient communities.

The COPD Winter Readiness project is a collaborative, quality improvement programme. Implemented at an ICB level aimed at providing additional resources into primary care to accelerated timely and equitable access for patients with moderate to severe COPD to appropriate care and treatment, by deploying a digitally enabled, pathway to proactively identify, risk-stratify, and triage patients to appropriate care at the population level without additional primary care capacity requirements.

This is the second of 2 phases covering 20 Norfolk and Waveney GP Practices funded by Norfolk and Waveney ICB covering 37 practices. Triple lock funding approval - ICB NP348 awarded on 04/08/25