The PCT's quality improvement facilitator, supported by a COPD specialist nurse, worked to improve COPD and diabetic services across 15 practices within the collaborative.

Much of the work centred on developing patient care pathways within secondary care. This was led by the specialist nurse who, with her colleagues in the COPD team, set up a service which includes hospital respiratory services, skills workshops, spirometry testing and dieticians' assessments.

The service aimed to reduce unnecessary hospital admissions, reduce the need for GP consultations and increase appropriate referral to secondary care. In terms of spirometry, there was a 94% improvement.

A consistently high number of Plan-Do-Study-Act (PDSA) cycles were submitted by practices, including one from a surgery where their COPD Register showed that from 47 records, 28 patients needed spirometry and the remainder had varying levels of COPD from moderate to severe. The work to increase effective spirometry was carried out by the practice nurse and further work was carried out with the hospital COPD team. Three months later, all 28 patients were reviewed and appropriate actions were found to have been taken.

A COPD management pack was developed with the programme and presented to the Improvement Foundation.

In different practice, the audit clerk ran several searches in cooperation with the acute trust. The results showed that from 20 patients, 14 patients had no record of acute admission, two had no NHS number, one was not a patient at the practice and only 3 were correctly coded. Since then, all patients are now READ coded 8H2R and each month all admission data is shared with the practice from the acute trust to validate and input on the IT system in the practice.

The project facilitator also led improvements in creating and piloting using handheld computers for records, and working with the chronic disease management integrated pathway facilitator looking at gaps in data and discharge information.