Primary Care COPD Risk Stratification and Population Health Service

This opportunity invites Primary Care Networks (PCNs) and primary care organisations to deliver integrated specialist respiratory services for identifying and managing Chronic Obstructive Pulmonary Disease (COPD) across Hull and East Yorkshire. The project aims to develop and implement a specialist-led neighbourhood model of care using a digital risk stratification tool powered by linked health system data. This tool will proactively identify high-risk COPD patients, enabling early preventative interventions and improved access to specialist care within community settings. PCNs will work collaboratively with Hull University Teaching Hospitals NHS Trust's specialist respiratory services to identify, review, and manage high-risk patients while building respiratory capability within primary care. The project will test the feasibility and impact of this neighbourhood approach to generate learning for wider adoption across the Humber region and beyond. Eligible providers must be PCNs or primary care organisations serving a registered population of at least 20,000 patients with recorded QOF COPD prevalence exceeding 2.0%, demonstrating experience managing respiratory disease in their communities. Ideally, 2 contracts will be awarded. Organisations already participating in concurrent COPD integrated risk stratification projects are ineligible. If more than two compliant applications are received, selection will prioritise those serving populations with the highest COPD prevalence.