

Victoria Harding
Wellbeing Lead
Titan PCN Luton Bedfordshire
The Challenge
In her role as Wellbeing Lead in the PCN, Victoria became aware that an increasing number of patients were contacting the surgery for advice and support around their Chronic Obstructive Pulmonary Disease (COPD). In particular, when patients had a COPD review over the telephone, it was difficult to thoroughly assess their inhaler techniques and identify environmental factors that might be exacerbating their condition, potentially leading to poor disease management. The PCN did not have access to specialist asthma nursing provision.
As Luton is in the top 10% of most deprived areas nationally, Victoria knew that addressing COPD health inequalities in her PCN was likely to be a complex issue, involving various factors such as social factors, lifestyle choices, access to healthcare, and the availability of support networks.
In addition, while conducting home visits, Victoria noted several patients who were isolated and not accessing healthcare services. Many had not received necessary vaccinations or education about inhaler use and self-management techniques for their long-term health conditions. This was further complicated by long waiting times to access pulmonary rehabilitation services.
Patient feedback
“I’m so thankful for my home visit and the information and support I’ve been given.”
“I now understand the difference between my inhalers and what they are for and do. This has already made a difference to me in just a week!”
“I have benefitted from the education about my COPD as well as understanding the effects of diet on management of my diabetes as well.”
The Innovation
Following the learning gained from the CARE programme, Victoria used the De Bono thinking hats model* to assemble a project team and plan how to address these challenges.
Victoria and her team, including Care Coordinator Helen Joynson, developed a pilot project to support the identified group of 595 patients diagnosed with COPD in 2023, with an increase of 50 in 2024 to date.
Initially, patients were invited to access the well-being services via letters, texts, and emails to speak to a team member, where a holistic assessment was conducted. This assessment focused on the patient’s well-being rather than the COPD itself and included:
- Assessment of social support and current activity levels
- Current clinical support
- Current medication being taken
- Vaccination status
At the assessment, the team conducted various questionnaires, including the COPD Assessment Test (CAT), Malnutrition Universal Screening Tool (MUST) Score, and Medical Research Council (MRC) Breathlessness Test. If these highlighted concerns, the team arranged a home visit. Once the assessment was completed, any outstanding issues were referred back to a clinician or appropriate staff member to address.
Victoria and her colleague, Care Coordinator Helen Joynson, visit patients in their homes to identify any further support needed. They provide patients with information on secondary and local options for support, such as the British Lung Foundation videos on inhaler technique, including the need to wash the ‘spacer’ regularly.
The team can make onward referrals to social services and local authorities, as well as Active Lifestyle Luton. Additionally, they have developed a fact sheet that is given to patients.
The team schedules welfare check follow-ups, including 3-monthly reviews and a retest of the previous questionnaires to gauge improvement.

The Impact
- Improved patient education, activation, and self-management
- Reduction in isolation
- Increased social activity and improved well-being
*Six Thinking Hats is a simple, effective parallel thinking process that helps people be more productive, focused, and mindfully involved. Read more here https://www.debonogroup.com/services/core-programs/six-thinking-hats/