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Meet the team: CLEMATTIS- COPD Lung Education, Management and Treatment Through Integrated Support


  • Cathryn Winchcombe, Directorate Manager Medicine
  • Natalie Young, Deputy Directorate Manager Medicine
  • Dr Bhatia, Respiratory Consultant
  • Dr Abdelaziz, Respiratory Consultant
  • Heather Palmer, CCG
  • Dr Gideon Smith, Consultant Public Health
  • Michelle Cunningham, Specialist Respiratory Nurse,
  • Catharine Cornell, Specialist Respiratory Physiotherapist
  • Dr Asad Ali, GP Neighbourhood lead Denton Neighbourhood


Tameside and Glossop has one of the highest COPD prevalence figures across the North West and continually high rates of admissions for COPD (8,588/1,000 population) compared to the North West (6,200/1,000) and England (4,698/1,000).  Mortality in Tameside and Glossop in 2016 was approximately 2,000, of which 657 of these (31%) were respiratory related. Respiratory disease has the highest mortality rate within Tameside and Glossop ahead of cancer and heart disease.  As part of a currently identified system-wide Respiratory Pathway Programme to address these health inequalities, the Service Improvement Manager organised some workshops with a wide range of stakeholders across the community and acute settings.  Great discussion and engagement has meant that numerous ideas have been developed within these workshops which are forming the basis for new service offers, closer MDT working, and GP-based stratification and engagement of individuals with pre and current COPD.  We have scoped initial data around where we can have the most impact, looking at ‘frequent fliers’ and the neighbourhoods they live in, support from digital offers and third sector agencies, and patient feedback on what elements they feel are missing for them.


At each workshop held there has been a lot of discussion around how COPD patients are supported with information and advice, and how this could be delivered in a way that the individual would ‘take on board’ more.  Patient feedback about how this could be achieved focussed on ‘buddy’s’ and how talking to someone who also has COPD makes receiving and believing this information far more effective.  A lot of material is shared with patients in the acute setting which often becomes a large pile of disparate leaflets and information sources which they never refer to again, or only do so when they have an exacerbation or emergency episode.  Many of the teams who have developed these materials are trying to promote self-management and self-care as way of increasing psychological wellbeing i.e. smoking cessation, pulmonary rehabilitation, exercise to extend function.  Key to all of these is the patient believing the information and that the support will work for them; which is where using a peer support network of COPD individuals to share and discuss this would work well.  There is also some thought around developing a patient held care plan which could be kept within the bag for completion by all healthcare parties to support cross pathway care.  A clear flower logo (Clematis) on the bag and any resources developed would indicate the COPD outcomes as part of this Q-Exchange initiative.


We would expect that patients will feel an increased sense of confidence when managing their COPD condition (PAM or similar metric), know who to contact for support (n= referrals to pulmonary rehabilitation, respiratory physios and nurses), link into health promotion services (n= smoking cessation referrals, Live Active exercise classes) and appreciate that there are people similar to themselves who manage their conditions well.  Staff are keen to make sure that the education and management information they produce and sessions that they offer provide the best support for COPD patients.  Uptake on pulmonary rehabilitation would be a key outcome, alongside reduced readmission rates, reduced length of stay and activation around medicines and inhaler technique.  Using a group of peer support individuals to engage with patients should develop new working relationships within both healthcare professional groups and third sector health and wellbeing organisations.


The support from this funding would give us a great resource that could be shared across any healthcare organisation working with COPD or any other Long Term Condition group as the idea has transferable objectives.  The Q Community would be able to use the template/ idea for peer support engagement work within their own organisations, and hopefully the Clematis logo as an identifier for cross pathway work.  We envisage that we would share the outcomes from our work through a Blog, Twitter for our developed CLEMATTIS logo, training and education resources; and patient stories for impact

How you can contribute

  • What resources would be good to include?
  • Have you developed any cross-pathway patient-held care plans?
  • Have you used virtual engagement options e.g. Tablet based Apps etc, in peer support conversations?


  1. Guest

    Caroline Bruckner-Holt 2 years, 10 months ago

    Dear Wendy and team,

    I work within Palliative Care and I suppose we gently advocate the idea of peer support and information giving informally within our day hospice environment. However, the idea of creating a more formal toolkit and training fellow patients to engage with each other and talk about pertinent topics is something I had never considered and the idea in my community patient cohort is a very interesting one.

    I hope that your bid for funding is successful and that many Q members can learn from your project if you are able to create a peer support engagement template on completion of the project as you hope.

    1. Hello Caroline

      Thank you ever so much for your comment and support.  I'm really hopeful if we're successful that we can develop and share our peer approach for general long term conditions use.



  2. The idea of supporting patients, particularly with COPD, but translatable to many other LTCs through peer support is great. I could imagine a similar set up for the diabetic patients I look after. You might find that your CCG is looking at similar models and, if so, you could use some of their work to support your bid.

    1. Hello Hein

      Thanks for the comments, and yes we feel it would be a transferable model to other LTC's; we are working closely with our CCG already on this idea and others as part of some wider Respiratory pathway work

  3. Guest

    Excellent idea of peer support for this group of patients to help them self manage their condition. The outcomes listed will support the success of this programme of work.

    1. Thank you Liz

      Appreciate your comment and support...we hope so too!

  4. Guest

    Elizabeth Bradbury 2 years, 11 months ago

    Wondered if there were any digital innovation options (a virtual 'bag') around access to this information or ways to link paper-based advice with online options in line with the digital agenda in Greater Manchester?  Sounds an interesting project esp the peer-led part. Good luck.

    1. Thanks Elizabeth and Emma

      the digital bag isn't something we'd thought of so thank-you for the prompt on that one...I guess we kind of got sucked into thinking our demographic might not be as tech-savvy but that's a poke to us to not think too narrowly I feel!

    2. Hi Wendy

      Building on Elizabeth's digital idea - we have used films for peer support which have been very helpful to patients and carers, which could be part of a digital bag? Best wishes

  5. Hi all

    I noticed a different a exchange bid related to PR but there may be some opportunities for shared learning. Hope this is helpful :


    1. Guest

      Helen Beadle 2 years, 10 months ago

      Hi All,

      I'm part of the team that has submitted the Q-exchange bid to expand our work in pulmonary rehabilitation and 'buddies'. We have had some really positive feedback so far from patients, staff and the volunteers themselves. The question I had for your project is around how you intend to recruit and manage the volunteer buddy service? One of the issues that we have encountered is around the recruitment process itself but also in working with a group of patients who are incredibly motivated to give back to the service and sometimes to the detriment of their own health. We are also at the point of developing more 'training' tools for the buddies as they are not infrequently encountering difficult conversations as the patients feel able to share sensitive and very personal information with them. However the concept of training for volunteers is in itself a controversial issue.  It would be great to discuss this further and will watch your project with interest.

  6. Hi Wendy and team

    Thank you for sharing your idea!

    Peer support in this way has been shown to have many benefits and I believe in Cancer care there's evidence about its impact (I'll try and dig out some journals if that's helpful

    You've listed some great ways you'd measure the impact and I think the softer measures such as how confident a patient feels is a good one to include. I wondered if you'd be creating a control group so that you could compare the intervention more fully and know if that particular intervention led to the outcome?


    Good luck and all the best.

    Dimple. Q Programme Manager

    1. Thanks Dimple...any cancer refs would be great so yes please on sharing those!  I think as we will have patients in the community being given COPD diagnoses there will be the potential to compare self-efficacy in some way with this, but yes some thought on the control group might be good.

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