Scope
Reference
2025-041
Description
Chronic Obstructive Pulmonary Disease (COPD) exacerbations have a considerable impact on healthcare costs and mortality rates, with over one-fifth of patients hospitalised for a COPD exacerbation for the first time and subsequent mortality within one year of discharge. Exacerbations of COPD account for one in every eight admissions, increasing by around 13% each year and are the second largest cause of Emergency Department (ED) admissions in the UK.
COPD exacerbation's significantly rise during colder months, with approximately 50% increased hospital admissions for COPD patients in winter compared to summer months. For every degree drop in temperature below 5 °C, there is a 10.5% increase in primary care respiratory consultations and a 0.8% increase in respiratory admissions.
The cost of respiratory care for COPD across Norfolk and Waveney is estimated to increase by 11% over the next ten years. Respiratory diseases are more prevalent in areas of social deprivation due to factors such as higher smoking rates, exposure to air pollution, and poorer housing conditions. These health inequalities lead to worse health outcomes and a widening gap between the rich and poor in respiratory disease mortality.
Early intervention and improving the treatment of people with COPD is part of ICB's Prevention Programme. This project seeks to utilise public health management data, mitigate health inequalities and improve accessibility through risk stratification and review utilisation of digital technology for patients with moderate to severe COPD, who would benefit from proactive patient identification, engagement and medicines optimisation
The project can only be delivered through to utilisation of LungHealth COPD software provided by NSHI. The software is a proven product, and carries full NHS digital accreditation (ORCHA and DTAC) and is listed on the LPP NHS Framework.
The Quality Outcomes Framework lists the prevalence of COPD in Norfolk and Waveney at 2.3%, (England average 1.9%) (QOF, 2021-22). N&W ICB serve a combined population of 24,429 Chronic Obstructive Pulmonary Disease (COPD) patients.
This project supports the N&W ICS five-year joint forward plan (N&WICS, 2025) and the development of integrated care. Four key themes: Driving integration; Prioritising prevention; Addressing inequalities; Enabling resilient communities.
The COPD Winter Readiness project is a collaborative, quality improvement programme. Implemented at an ICB level aimed at providing additional resources into primary care to accelerated timely and equitable access for patients with moderate to severe COPD to appropriate care and treatment, by deploying a digitally enabled, pathway to proactively identify, risk-stratify, and triage patients to appropriate care at the population level without additional primary care capacity requirements.
This is the second of 2 phases covering 20 Norfolk and Waveney GP Practices funded by Norfolk and Waveney ICB covering 37 practices.
Triple lock funding approval - ICB NP348 awarded on 04/08/25
Contract 1. COPD Winter Readiness
Supplier
Contract value
- £250,000 excluding VAT
- £300,000 including VAT
Above the relevant threshold
Date signed
4 November 2025
Contract dates
- 4 November 2025 to 30 September 2026
- 10 months, 27 days
Main procurement category
Services
CPV classifications
- 48180000 - Medical software package
- 72200000 - Software programming and consultancy services
- 72300000 - Data services
Key performance indicators
| Name | Description | Reporting frequency |
|---|---|---|
| Eligible patients | Number and percentage of patients coded as having COPD, including break down by deprivation, location (place, PCN and practice), sex and ethnicity |
1 months |
| High risk patients | # and % of patients with COPD categorised as high and moderate risk following risk stratification, including break down by deprivation, location (place, PCN and practice), sex and ethnicity |
1 months |
| Levels of contact | # and % of patients with COPD categorised as high and moderate risk who have been contacted, including break down by deprivation, location (place, PCN and practice), sex and ethnicity |
1 months |
| Patients reviewed | # and % of patients with COPD categorised as high and moderate risk who have been reviewed, including break down by deprivation, location (place, PCN and practice), sex and ethnicity |
1 months |
| Recommended medication change | # and % of patients who have been reviewed and have had a recommended medication change, including break down by deprivation, location (place, PCN and practice), sex and ethnicity |
1 months |
| Adherence to guidelines | # and % of patients who are prescribed medication in alignment with guidelines, including break down by deprivation, location (place, PCN and practice), sex and ethnicity |
1 months |
| Care planning | # and % of patients who have an agreed care plan in place, including break down by deprivation, location (place, PCN and practice), sex and ethnicity |
1 months |
Other information
Conflicts assessment prepared/revised
Yes
Procedure
Procedure type
Direct award
Direct award justification
- Single supplier - intellectual property or exclusive rights
- Single supplier - technical reasons
The project can only be delivered through utilisation of LungHealth Chronic Obstructive Pulmonary Disease (COPD) software provided by NSHI. The software is proven product and carries full NHS digital accreditation (ORCHA and DTAC) and is listed on the LPP NHS Framework.
Early intervention and improving the treatment of people with COPD is part of ICB's Prevention Programme. This project seeks to utilise public health management data, mitigate health inequalities and improve accessibility through risk stratification and review utilising digital technology, of patients with moderate to severe COPD, who would benefit from care planning and optimal guideline driven medication therapy.
According to Quality Outcomes Framework, Norfolk and Waveney: COPD prevalence equates to 2.3%, (England average 1.9%) (QOF, 2021-22). NHS Norfolk and Waveney Integrated Care Board (ICB) serving a combined population of 24,429 COPD patients. Project supports NHS Norfolk and Waveney ICS five-year joint forward plan and the development of integrated care. Four key themes: Driving integration; Prioritising prevention; Addressing inequalities; Enabling resilient communities.
The COPD Winter Readiness project is a collaborative, quality improvement programme. Implemented at an ICB level aimed at providing additional resources into primary care to accelerated timely and equitable access for patients with moderate to severe COPD to appropriate care and treatment, by deploying a digitally enabled, pathway to proactively identify, risk-stratify, and triage patients to appropriate care at the population level without additional primary care capacity requirements.
Supplier
NSHI LIMITED
- Companies House: 05327448
33 Turbine Way
Swaffham
PE37 7XD
United Kingdom
Email: accounts@nshi.co.uk
Region: UKH17 - Breckland and South Norfolk
Small or medium-sized enterprise (SME): Yes
Voluntary, community or social enterprise (VCSE): No
Supported employment provider: No
Public service mutual: No
Contract 1
Contracting authority
NHS NORFOLK AND WAVENEY INTEGRATED CARE BOARD
- NHS Organisation Data Service: QMM
8th Floor, County Hall, Martineau Lane
Norwich
NR1 2DH
United Kingdom
Region: UKH15 - Norwich and East Norfolk
Organisation type: Public authority - sub-central government