Neighbourhood COPD Risk Stratification Population Health Project

Scope as published

PSR MSP Process for the provision of primary care respiratory services for the identification and treatment of COPD. CPV code: 85121000-6 Medical Practice & Related Services This project aims to develop and implement a specialist-led, integrated neighbourhood model of care for people living with COPD across Hull and East Yorkshire. Part of the project will involve developing a risk stratification tool, utilising linked system level data held by Humber and North Yorkshire Integrated Care Board (ICB), Appendix 1 sets out the proposed data flow to support COPD Population Level Health Management. By developing, testing and implementing a population health, digital risk stratification tool, the project will proactively identify high-risk patients, support preventative intervention, and improve access to specialist care within community settings, in line with NHS priorities to shift care from hospitals to communities and from treatment to prevention. Primary Care Networks (PCNs) will be invited to participate as delivery partners in the implementation, ongoing development, and evaluation of the proposed model. Working collaboratively with specialist respiratory services provided by Hull University Teaching Hospitals NHS Trust, participating PCNs will support the identification, review, and proactive management of high-risk patients, whilst contributing to the development of respiratory capability and capacity within primary care. The project will test the feasibility and impact of this neighbourhood-based approach and generate learning to inform future commissioning decisions and potential wider adoption across the Humber region and beyond. A suitable Provider shall be a Primary Care Network (PCN) or primary care organisation serving a registered population of at least 20,000 patients, demonstrating the scale, infrastructure, and capability required to deliver high-quality, sustainable respiratory services within populations where the recorded QOF COPD prevalence exceeds 2.0%, demonstrating experience in meeting the needs of communities with a significant burden of respiratory disease. Ideally 2 PCNs will be awarded contracts. Please note that organisations already participating in, or progressing towards contract for, another COPD integrated risk stratification project involving partnership working between specialist respiratory services and primary care will not be eligible to participate in both projects concurrently. In the event that more than two compliant Expressions of Interest are received, providers will be selected based on COPD prevalence, with priority given to those serving populations with the highest prevalence. Please refer to the full Services Specifications document for further details.

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