• Led by Portsmouth Hospitals NHS Trust, in partnership with Wessex Academic Health Science Network.
  • Aimed to reduce the time taken to identify and treat poorly controlled chronic obstructive pulmonary disease (COPD) in patients from five GP surgeries in Portsmouth.
  • Implemented a model of proactive COPD assessment combined with individualised self-management plans.
  • Resulted in improvements in disease control and quality of life for 100% of patients involved, plus reductions in unscheduled care.

One million people in the UK have diagnosed COPD and an estimated two million currently remain undiagnosed. The condition accounts for 30,000 deaths each year.

MISSION-COPD is an innovative model of COPD assessment and care that aims to identify people with poorly controlled COPD so that they can be diagnosed and treated earlier.

The project team from Portsmouth Hospitals NHS Trust proactively identified patients with undiagnosed or high-risk COPD from five GP surgeries in Portsmouth. They then conducted a comprehensive assessment of symptom control, quality of life and triggers during special COPD clinics, held at the GP surgeries. The clinics were held at weekends to improve accessibility. This was then followed by specialist evaluation in hospital by a COPD team if necessary. 

Each patient and surgery received an individualised self-management plan with a summary of results, recommended treatment changes and additional diagnoses.

The project team analysed health care usage, symptom scores and patient-reported measures before and after the intervention, using GP data and patient interviews/questionnaires. They found that the intervention significantly improved rates of diagnosis, assessment of co-morbidities and treatment of COPD, as well as improving disease control and quality of life in all 108 patients involved. It also significantly reduced unscheduled care, such as emergency department visits and hospital admissions.

Feedback on MISSION-COPD from health care professionals and patients was overwhelmingly positive, with 100% of patients saying they would recommend it to friends or family, and most reporting improvements in their COPD knowledge and self-management confidence.

Challenges were encountered relating to variable engagement of primary care partners, acceptability of delivering care at weekends and limitations to service provision. Importantly, lessons learnt could be applied during potential expansion of this innovative model to other long-term conditions and scale up across the NHS. There is now ongoing work to expand the project to other localities in Portsmouth.

This Innovating for Improvement project ran from the beginning of May 2015 until the end July 2016.