Transformation Directorate

Hearts, minds, and original thinking: scaling a technology-enabled remote monitoring hub to support thousands of people at home across Cheshire and Merseyside.

Delivered in partnership with the AHSN Network.

Engagement, insight, evidence and original thinking in Liverpool has paved the way for the rapid expansion of a remote monitoring hub that now supports thousands of people in nine localities across Cheshire and Merseyside.

Borne out of a 2011 partnership between Mersey Care NHS Foundation Trust and Liverpool CCG involving 50 patients, the hub has supported up to 5,500 people daily to safely manage their health and care at home across clinical pathways including, COPD, heart failure, Type 2 diabetes and Covid.

Following extensive strategy and engagement groundwork, the telehealth hub began to significantly increase capacity from 2014.

It has subsequently been able to scale and adapt to meet challenges including the pandemic while, more generally, achieving its aim to maximise finite resources to best support people who are living longer and often with more comorbidities.


Many people in Liverpool and the broader region, which has a mix of affluent and deprived areas with a life expectancy variation of up to 10 years, have long-term conditions.

Population health data identified cardiovascular disease as particularly prevalent and, along with COPD, a significant cause of death among the young.

The hub was conceived as a new, distinct service to help meet clinical needs of such patients.

“A great deal of endeavour was required over a sustained period to win hearts and minds, mainly because we were delivering something completely new. “Like most new things, there was some scepticism and nervousness around using digital technology to support patients remotely. “Building trusted relationships and confidence through engagement, including sharing clear evidence of the benefits to patients and GPs, has been absolutely key.”

Peter Almond, Cheshire and Merseyside Remote Monitoring programme manager

The hub is staffed by professionals whose sole role is dedicated to working within the specialist service.

Such clearly defined responsibilities, now carried out by 30 FTE staff including Band 7 specialist nurses and Band 6 tele-health advisers, reflect a now-mature, service specific structure that supports swift, safe development of capacity and capability.

Getting the right skill-mix has been critical to safely increasing the nurse-to-patient ratio from ​​1:40 to 1:300 for long-term condition monitoring, with additional support to nurses from healthcare assistants and administrators now in place.

Ensuring both staff and patients have understanding and trust in the service through regular engagement and education has also been vital to its success.

“We have a set of referral criteria to identify patients who are clinically safe to be monitored in the community. “Each pathway has robust clinical governance to ensure the clinical safety and quality of care delivery and provide the best care to our patients, keeping them safe in the community, facilitating early supported discharges from hospitals via virtual wards, and improving the patient experience. “Clinical leadership is the key to the safe implementation of end-to-end technology-enabled long-term condition monitoring at home.”

Nisha Jose, Health Technology and Access Services clinical team leader at Mersey Care NHS Foundation Trust


The hub was created as a new solution to meet specific needs identified through a mix of local and national population health data analysis and risk stratification.

Its operation, which also incorporates virtual wards and supports care homes and people with learning disabilities, is underpinned by strong project management and service-specific processes, standards and governance, including performance management metrics and regular benefits reporting.

The service has clinical advisory boards that support the development of new local pathways, and a remote monitoring programme board that focuses on potential benefits and prioritises the release of funding, including financial support provided by NHS England.

Peter said:

You need to identify what the clinical problem is first and then work on the whole solution. It’s essential to get the right skill mix, governance structure and standards in place alongside the technology.


Stakeholder engagement, consistent co-production, educational support and regular evidence-based reporting have all contributed to a significant shift in expectation among health and care professionals and increased confidence among patients.

The team aims to foster an empowered culture within the population it serves by instilling confidence and knowledge, encouraging informed condition management outside of hospital and within discussions between patient, professionals, family and friends.

Peter said:

People are telling us that their confidence has improved in managing their condition, with some coaching from the nurses. We’ve also reached the point where GPs and other clinicians don’t question the use of technology-enabled remote monitoring. Instead, they question why it wouldn’t be used.

Tools and technology

Patients use an app on their phone or tablet to send information to the hub on their individual health or wellbeing needs, such as vital sign readings like blood pressure or temperature, symptoms of anxiety and depression, or problems with everyday tasks like eating or getting dressed.

When a patient inputs their readings, this information reaches the hub via the Docobo digital platform, with intervention rules and pre-set thresholds triggering an alert if a patient’s readings are outside of their personalised ‘normal’ threshold.

The team can quickly identify if the patient’s condition is deteriorating and determine the most appropriate course of action, such as increased monitoring or triage to the GP, community service or hospital.

Peter said:

This is about much more than getting the kit up and running and giving it to patients, or about just obtaining data and transferring that data on to somewhere else. This is a transformational piece of work. “You’ve really got to think about the whole infrastructure and how it interfaces with hospitals, GPs and community services and the relationships between those teams. “It isn’t something you can do overnight. It takes tenacity, it takes commitment, and it takes resilience.

The hub, which operates between 8am and 8pm 365 days a year, can ​​provide 4G-enabled smart devices to patients that don’t own a personal phone or tablet, who could otherwise have been excluded from accessing the service.

It also offers training on the app to everyone, regardless of whether they have a personal or NHS device.

Peter said:

Patients are loaned the kit for as long as they require the service. It’s about digital inclusion and not creating further health inequalities. If the patients don’t have their own smart device, we can provide one. If they don’t have data, we can cover that. If they don’t know how to use a device, we can train them.

Benefits and impact

  • ​​​Since the service began, emergency admissions to hospital among remote-monitored long term condition patients have consistently reduced by 22.3 per cent on average, compared to those who are not.
  • Patient self-reporting suggests a reduction of up to 40 per cent in use of health and care services including visits to GPs, community nurses and matrons.
  • Nursing and clinical teams say the service supports them with effective time management.
  • Teams in different localities have increased cross-boundary working across primary, acute and community settings.
  • ​​​Patient Reported Outcome Measures show increased confidence and awareness in managing their conditions, with 80 per cent of patients reporting increased confidence in managing their long-term conditions.
  • Families and friends report they have increased peace of mind, knowing that their loved one is being supported at home through technology-enabled remote-monitoring.

Heart failure virtual ward patient Colette Melia said:   

Being on the heart failure virtual ward has made me feel really reassured. If there is anything the nurses are concerned about from my data they can contact the on-call consultant cardiologist – perhaps they will advise that I reduce or increase medication. It’s almost like having a doctor on tap! It’s a really personalised service and is really tailored to my needs. The nurses are so well trained, so it gives you confidence. It’s giving me a better quality of life - physically as well as mentally.  Because it gives me more time to spend with my family. It also allows more time for me to spend on basic pleasures – reading and things like that. I couldn’t concentrate before as I was so worried. It gives you your life back.

Find out more

You can read the full case study 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