• Project led by Southampton University Hospitals NHS Trust.
  • Focused on primary and secondary care of COPD patients within Southampton.
  • Aimed to improve the care of COPD patients, with more patients self-managing their condition and fewer hospital admissions.
  • Developed an educational package to raise the profile of COPD in the primary care community and established a consultant-led, community-based programme of support for patients frequently admitted to hospital.

The Southampton University Hospitals team developed an educational package to raise the profile of chronic obstructive pulmonary disorder (COPD) in the primary care community and help practitioners to improve patient care in this area. The programme aimed to:

  • improve diagnosis rates
  • reduce the exacerbation rate of COPD
  • reduce hospital admissions
  • support patients to self-manage their condition.


The project involved a combination of face-to-face training for GPs and practice nurses, online information for practitioners and patients, and specialist consultant-led but community-based support for patients who were frequently admitted to hospital. 

Patients who had three or more admissions in the previous year had a 'discovery interview' in their home with a consultant and a specialist nurse, to review their health needs, optimise their treatment and investigate why they needed to come into hospital. These patients were given 24 hour access to a community nurse and could be seen by a consultant within 24 hours.

Who was involved

The project spanned primary and secondary care. The primary care project was delivered within NHS Southampton City and included 36 GP practices.


  • GPs and practice nurses developed new skills and knowledge in areas including spirometry, diagnosis and management.
  • Hospitals benefited from fewer admissions..
  • Patients received a more accurate diagnosis and more structured, evidence-based treatment, while ‘frequent flyer’ patients had fewer hospital admissions..

For more information see the npj Primary Care Respiratory Medicine website.


Competition among providers made the delivery of this project more challenging than expected. For example, it became apparent that practice nurses were in charge of COPD patient pathways and that patients often bypassed GPs and self-presented at hospitals.

Further reading