• Project led by NHS Redbridge.
  • Focused on COPD care at ten GP practices.
  • Aimed to raise standards of COPD care and reduce hospital admissions by empowering patients to negotiate high quality care and changing attitudes to COPD management in GP practices.
  • Developed an IT system that produces a personalised scorecard for COPD patients, to help them to access evidence-based interventions and actively manage their condition.

The NHS Redbridge team developed an IT system which provides personalised information to COPD patients and their GPs. The aim was to raise standards of care and reduce hospital admissions by empowering patients to negotiate high quality care and changing attitudes to COPD management in GP practices.

The IT system extracted information from primary care databases to create personalised patient scorecards. Patients, GPs, practice nurses and practice managers worked together to design the scorecard, which focused on six evidence-based interventions based on NICE guidelines, including annual reviews, stopping smoking and support with self-management.

The scorecards were sent to patients along with a letter advising them to see their GP to discuss further interventions, plus information about community-based services that could enable exacerbations to be managed at home rather than in hospital.

The system was also used to generate reports comparing quality with primary and secondary care costs for each patient. These reports were sent to GPs and patients to highlight the association between quality and cost.

Who was involved

The project involved ten GP practices in the NHS Redbridge area.


The quality scorecards were an effective tool for changing behaviours and attitudes around COPD care within practices, and encouraging GPs to create a more proactive and positive relationship with patients. The scorecards revealed variations in practice quality and exposed challenges within the system, and became a great motivator for change and improvement.


The short timescale for the project meant no meaningful quantitative results were seen for admissions and patient levels. However, the qualitative results were significant.

Further reading

Learning report

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Press release

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