What’s this project all about?
A neighbourhood health team in Pontefract and Knottingley is taking a more proactive approach to supporting people living with chronic obstructive pulmonary disease (COPD) - helping people get the right support before they become unwell and need to go to hospital.
The work is part of the Neighbourhood Health approach across West Yorkshire, where partners come together with a shared ambition to transform health and care around neighbourhoods, putting people and communities at the heart of how we work.
Across Wakefield District, six Neighbourhood Health teams are focusing on three groups of people who are more likely to need hospital care:
- people living with dementia
- people with COPD
- people nearing the end of their lives
Although these groups make up just 3.7% of the local population, they account for more than a fifth of all unplanned hospital admissions and almost a third of the days people spend in hospital following these admissions.
Finding people who may need extra help
The Pontefract and Knottingley team used a data tool to identify people with COPD who were most likely to need hospital care in the next three months. The tool is more than 90% accurate and helped the team see where extra support could make the biggest difference.
It showed that people with COPD were more than 50% more likely to need hospital care than people living with dementia and three times more likely than people nearing the end of their lives. This led the team to make COPD a particular focus.
Health and Wellbeing Coach Kelly Pritchard said:
“The data helped us see where we could make the biggest difference. It showed us that people with COPD were at particularly high risk of needing hospital care, so we wanted to act before they reached that point.”
Bringing the right people together
Since December 2025, the team has been holding regular meetings with health and care professionals to look at the needs of people with COPD. Multidisciplinary team (MDTs) - which bring different professionals together to agree the best support for someone - have improved the way people are referred for support, helping to make sure people are not sent back to their GP when they would benefit from more help.
People at medium or high risk of becoming unwell have also been offered extra COPD reviews. These reviews can include a ReSPECT form, which records a person’s wishes about their future care if they become too unwell to make decisions for themselves. People can also be referred to a health coach for help with issues such as anxiety and breathlessness.
Kelly added:
“We’re trying to look at the whole person, not just their COPD. We want to understand what is happening in their lives, what might be making their symptoms harder to manage and what support could help them stay well at home.
“Breathlessness can have a huge impact on people’s confidence and everyday life. Sometimes people stop doing things because they are worried about getting out of breath. The health coaching gives them someone to talk to and practical support to help them manage that.”
Helping people breathe better
The team is also offering Breathing Better, a community exercise and education programme for people living with severe breathlessness. The programme was developed through a partnership between Wakefield Council and MYTherapy. It helps people understand and manage their symptoms, while building their strength and confidence.
The programme development was funded through Core20PLUS5, a national NHS programme that aims to improve health for people who experience the greatest health inequalities. It offers another option for people who may benefit from pulmonary rehabilitation, which is a programme that helps people with lung conditions improve their fitness and manage their symptoms.
The first 12-week Breathing Better programme supported eight people.
Kelly said:
“Breathing Better gives people a chance to build their confidence gradually. It’s not just about exercise - it’s about understanding your condition, learning ways to manage your symptoms and feeling more confident about what you can do.”
Early signs that the approach is working
Since the first COPD team meeting in December 2025 until June 2026, the team has seen some encouraging changes among the cohort it is supporting:
- Flu vaccination rates increased by 6.9%
- Expected A&E attendances fell by 19.6%
- Expected COPD hospital admissions fell by 12.7%
- GP consultations fell by 9.8%
These early results suggest that giving people more support earlier could help them stay well and reduce the need for urgent care.
What people think
Nine people who received COPD support through Breathing Better gave feedback about the programme. The results were very positive:
- 89% rated the service as excellent
- 100% said they would recommend the programme
- 67% felt much more confident managing their COPD
- 67% said the treatment helped a lot with their COPD
People said the support had “made me fitter” and “helped me understand my condition better”. One said: “I have gained lots of information from the group and health coach”.
Keeping the support going
The team has also set up a new COPD café at Ash Grove Medical Centre in Knottingley. The café takes place on the second Tuesday of every month and gives people with COPD a chance to have a cuppa, meet other people who understand what they are going through and continue to get support after completing programmes such as pulmonary rehabilitation or Breathing Better.
There is no need to book - people can simply drop in. The café offers:
- refreshments
- support from other people living with COPD
- occasional guest speakers
- tips for managing COPD
- occasional activities
Kelly said:
“We don’t want support to stop when someone finishes a programme. The COPD café is about keeping that connection going. People can come along, have a chat, ask questions and meet others who understand what living with COPD is like.
“It’s about helping people feel less alone and giving them somewhere they can come back to. Even a simple chat over a cup of tea can make a real difference.”
The team hopes the café will become a regular source of support for people living with COPD in Pontefract and Knottingley.
Find out more
For more information about the Pontefract and Knottingley COPD work, or to discuss taking part in a video, podcast or other communications activity, contact Kelly Pritchard, Neighbourhood Health Team Coach on kelly.
You can also read the 'Pontefract and Knottingley neighbourhood team’s proactive approach to supporting people with COPD' case study on a PDF file.