Transformation Directorate

Managing long term conditions remotely in the North West

What was the aim or problem?

Over eight years ago, Liverpool adopted a telehealth model to care for patients with long term conditions. This hub model (see below) has formed the basis of the new, digitally-enabled COVID Oximetry @ Home (CO@H) services now being expanded across Cheshire and Merseyside, enabling fast roll-out across the majority of its clinical commissioning groups (CCGs).

In Lancashire and South Cumbria, meanwhile, the COVID-19 pandemic delayed original plans to expand remote monitoring into regulated care settings such as care homes and supported accommodation. Resources were instead urgently redeployed to deliver home oximetry monitoring for COVID-19, again supported by digital technologies.

In both cases, the aims are to:

  • improve health outcomes for those recovering from COVID-19
  • enable faster discharge from hospital and reduce length of stay
  • reduce the demand on primary and secondary care, including preventing emergency admissions and 999 calls

Crucially, the experience and lessons drawn from establishing these digitally-enabled services are now directly informing plans to expand the use of similar technologies in other areas.

What was the solution?

The health technology used is a small, easy to use piece of equipment that works through the patient’s TV or a tablet. It enables the patient or their carer to take their vital signs, such as blood pressure, pulse, body weight, temperature and oxygen levels at home. Patients can also use it to get answers to simple questions about their health. The provision of education videos and ethos of the services, is to help people to more effectively self-manage their condition so they stay well, become more independent and reduce the likelihood of emergency hospital treatment.

The remote monitoring aspects of the system provide the clinical team with the information they need to monitor their patient’s condition, including any signs of deterioration or potential concern, meaning that the right support and interventions can be delivered when the individual patient needs it.

Using technology in the home, the clinical team is able to:

  • collect vital signs or symptoms remotely and compare them against defined rules to ensure that patients who need additional treatment or advice are identified
  • use symptomatic questioning to screen the patient’s health and wellbeing

The nurse will:

  • review any alerts alongside trends and previous notes or GP record
  • contact the patient by phone or video to assess the situation further if required
  • recommend action and coach the patient to manage their condition
  • provide education, coaching and support to enable people to better self-manage their medical conditions and lifestyle
  • escalate any concerns or problems back to the clinical team as appropriate

Operated by Mersey Care NHS Foundation Trust, this service is being extended beyond Liverpool hospital to other areas in the city region.

Peter Almond, Programme Manager at Mersey Care, said: “As a direct result of the pandemic, Mersey Care NHS Foundation Trust increased access to the telehealth and remote model, and we are now monitoring around 5,000 patients at any one time.

“This means that many more vulnerable people are being supported to better manage their own health in the short, medium and longer term. Any deterioration of their condition or problems they have noticed can be more rapidly identified, with appropriate advice, support and when needed investigation, care and treatment provided.”

What were the challenges?

  • This is a whole system approach and requires a change of mindset among staff, patients, their carers and the pathways into the service.
  • Everyone from patients, carers to clinical teams and managers will need to be educated in what the system involves and how to use it.

What is the impact?

Over 3,200 patients have been supported by digitally-enabled CO@H services across the two areas featured in this case study.

  • Up to 200 patients can now be safely monitored by a single nurse working in the Cheshire and Merseyside telehealth hub.
  • 81% of patients with oxygen saturation levels below 92 per cent were safely managed by the Telehealth Hub, resulting in 237 patients not requiring hospital treatment.
  • Only 3% of the 819 patients with oxygen saturation levels between 93% and 94% needed referral to a GP for review, saving 787 referrals into primary care.

Key actions and insights

We asked key members of these projects to highlight the key lessons they have taken from this work. Here are their reflections on the process so far.

The professional perspective

Taking a whole system approach to delivery

“The most important thing for us has been the way teams have pulled together, and the key to this has been a combination of good governance, strong project management and effective communications and engagement throughout. We had a clinical oversight group to scrutinise, challenge and trouble shoot as the service developed, and a working group to drive forward delivery on the ground. And particularly important was the Innovation Agency’s support in reaching out to stakeholders within each CCG in advance of roll-out – this was vital work which helped pave the way for us to rapidly introduce the service in areas that hadn’t used digital services like these before.”

Peter Almond, Programme Manager, Health Technology and Access Services, Mersey Care NHS Foundation Trust

Using ‘experts with experience’

“We learnt quickly from the CO@H roll out that people are the real drivers for any change in working processes and so as we expand telehealth solutions out into social care, we are recruiting ‘experts with experience’ change ambassadors who are passionate about transforming care for vulnerable residents. By tapping into their energy and enthusiasm, we’re using them as agents of change to encourage and support front line care and support staff to embrace technologies for the benefit of residents.”

Steve Tingle, Director for Digitisation in Regulated Care, Lancashire and South Cumbria Integrated Care System

Establishing a continuous learning process

“COVID-19 positive patients at this point were new to healthcare worldwide, as were the technologies employed to support them, so each day brought new knowledge and learning opportunities. We used continuous improvement methodology and the Plan, Do, Study, Act cycles to identify where change in practice or processes were needed, and we implemented a team-led change monitor for effectiveness and adaptation, if required.”

Helen Bradley, Matron, Integrated Urgent Care Service, Greater Preston, Chorley and South Ribble

The human perspective

“Colin Etheridge is typical of the patients supported by these technologies. The 67-year-old developed COVID-19 symptoms and was referred by his GP to his local CO@H service provided by Mersey Care.

“When his condition worsened, nurses arranged for him to go to A&E, where he was diagnosed with pneumonia. He was discharged with antibiotics but became more unwell. It was decided he should stay at home, supported by the remote monitoring service.”

Colin’s wife, Pauline, reflecting on their experience of using the remote monitoring service

“They’d constantly call and reassure me that the readings were okay. When they said ‘ring anytime’ they meant just that. It was just you and them, like you weren’t putting them out.I can’t express how fantastic a service this is. It was like having them in the room with you, at your side. I never felt I was on my own.”

Cathy Gillespie, Telehealth Clinical Team Leader, Mersey Care NHS Foundation Trust

People tell us how much security it gives them to have someone monitoring and giving advice. They’re scared, they may have breathing problems and they can’t have family or friends coming in to help. Once they know we’ll be there to monitor and on the end of the phone whenever they need us, people start to feel more reassured.

How is the technology working in practice?

We asked health professionals working with the digitally-enabled technology to describe the real-world impact on COVID-19 patients and their own working practices. Here are their personal experiences.

COVID oximetry at home monitoring has helped the service become more efficient

Cathy Gillespie, clinical team leader, describes how the at-home monitoring of patients has helped the service to be efficient and support a large number of patients during the pandemic.

COVID oximetry at home monitoring has allowed the team to support people effectively and swiftly

Nurse advisor Julie Bowman reflects on how the technology allowed the team to support people effectively, ensure swift hospital admissions when necessary and give reassurance to patients that they were being monitored closely at home.

Key lessons and next steps

Looking ahead, how might this project help to shape the future direction of health services in the region?

Members of the programme team outlined the 4 key lessons that are shaping their priorities for the future.

Lancashire and South Cumbria

Resetting clinical assumptions

One of the biggest challenges faced was around resetting clinical assumptions about the capability of remote monitoring solutions. Traditionally, telehealth models have supported patients in a stable condition, yet the profile and risk factors for patients on the CO@H pathway were clearly different as their health had the potential to deteriorate quickly and without warning.

The result was that we had to overcome significant concerns about implementing a remote system, with clinicians feeling these patients needed a more proactive service than could be provided remotely. Challenging these perceptions and demonstrating the clinical value of a digitally-enabled CO@H model quickly became a major focus of our engagement.

Flexing to meet local circumstances

The ambition was to implement telehealth solutions at a system level, it quickly became apparent that one size doesn’t fit all as local configurations are currently very different. A pragmatic approach was taken to roll out technologies in a way that reflected the make-up of services and service providers at an integrated care pathway (ICP) level.

Moving forward this twin track approach will continue, maintaining a pragmatic focus on supporting the needs of each locality, while scoping out proposals for integrated care systems (ICS) scale solutions that will help create a more integrated, system-wide clinical hub model over the long term.

To support this a rapid review was conducted looking at best practice at regional, national and international levels. The aim is to draw on successful models, like Mersey Care, while designing an approach that still feels locally relevant, connected to the needs of the local populations and which is fully funded by the local system over the long term.

Embracing a full spectrum of solutions

A final reflection is that remote monitoring is really a spectrum. Advanced telehealth systems Docobo work very well in a specific context, as shown in this case, but simple methods can be effective too. For example, some surgeries in the region asked patients to text their vital signs readings directly into EMIS as part of their management of long term conditions.

The need is to embrace a full range of solutions, with a clear sense of what’s proportionate, effective and easy to implement on the ground. The latter is a particularly key factor when clinical teams are under huge pressure.

As remote monitoring solutions are expanded to cover care homes, mental health and long term conditions, the same principle will be applied to support shaping future plans.

Key lessons and next steps for Lancashire and South Cumbria

Looking ahead, how might this project help to shape the future direction of health services in the region?

Members of the programme team outlined the four key lessons that are shaping their priorities for the future.

Cheshire and Merseyside

Reducing the barriers to uptake

One of the most important things learnt was the need to be flexible in terms of the technology, based on the needs and capabilities of the people being supported.

For CO@H services, there were three levels of monitoring and a more advanced app with a range of peripheral devices for patients on the virtual ward. For example, there was a text-based reporting system. This was designed to give the lowest possible entry point into the technology due to people’s familiarity with SMS messaging and a more traditional “analogue” service for those who cannot engage with technology at all.

The lesson to be adaptable and responsive is key, matching the level of engagement with technology to the patient’s individual circumstance. Having this tiered approach worked well in terms of helping to reach the widest possible range of patients.

Building a knowledge base for the future

Another key issue faced was around skills and resourcing. There is only a small cohort of people locally who have the knowledge and experience necessary to deliver this type of work, which places a limit on how quickly and how far it can be expanded.

It's important to have people who have a broad understanding of how the system works, both from a technical standpoint and from a practical perspective of how different staff members within a service actually use the technology. Building skills and knowledge base and ensuring good succession plans if people move on are both critical for allowing the use of remote monitoring technology to expand further in the years ahead.

Developing an intelligent, population level approach

Learning from all of these experiences, the plan is now to pivot back to the original aim of expanding virtual wards, embedding remote monitoring for long term conditions and exploring how care homes and mental health can be supported.

A model of having one ICS-level telehealth hub servicing the whole region is to be explored. A key part of this is our work with the CIPHFA platform, a repository of data from clinical systems across Cheshire and Merseyside, which support population health management.

Using the data to help identify patients who may benefit most from telehealth in future, moving to what is described as ‘intelligence-led nursing’ where the data will be used to utilise resources more effectively and ensure telehealth solutions support the right cohort of patients.

Find out more

You can read the full case study on the work across the region on our Innovation Collaborative workspace at FutureNHS.

Join the National Innovation Collaborative

The Innovation Collaborative is open to all NHS, social care and local authority staff with an interest in remote monitoring, providing access to peer-to-peer support, guidance and tools designed to help you implement a remote monitoring service.

Existing members can access the Innovation Collaborative Digital Health workspace on the FutureNHS platform. Alternatively, to join or ask any questions email