Transformation Directorate

Supporting vulnerable residents and those who live with frailty in the South West

NHSX is now part of NHS England's Transformation Directorate.

What was the aim?

The COVID-19 pandemic has been particularly challenging for staff working in various ‘out-of-hospital’ settings, delivering essential care at the front line.

While the South West fared better than many parts of the UK during the initial COVID-19 wave, its population of around six million people has a high proportion of elderly residents.

More than 23% of the population in the south west are of state pension age and above, compared to a national average of 18%. This is the largest proportion of any UK region, with many of these people classed as frail and living with multiple long term conditions.

In addition, a national study by the Care Quality Commission and National Office for Statistics showed at the peak of the COVID-19 wave pandemic in April 2020, there was a 134% increase in deaths of people with a learning disability compared to the same period in 2019. For two weeks during this peak period in the South West, the mortality rate of people with a learning disability doubled compared to the baseline. 

Our solution

The South West region, has ambitious plans to work together as an entire health and care system to make best use of available technologies to support vulnerable residents, in particular residents in care homes, those who live with frailty, and people with learning disabilities.

The region's shared objective is to improve outcomes for those most at risk, using technology as an enabler. While digital and remote monitoring technologies are vital elements in helping create further capacity in health and care systems, partners agreed that the approach should not be simply a technology programme. It is an opportunity to use a ‘learning by doing’ approach, which builds knowledge and skills to enable front line teams to co-produce real and lasting improvements for residents.

Dr Shanil Mantri, GP and Clinical Digital Advisor to West of England AHSN, said: “With the challenges of the COVID-19 pandemic, the ability to manage people remotely in care homes has become an essential tool in preventing any potential spread of infection. 

“Remote monitoring technologies have the potential to give clinicians (including GPs, community staff and hospital consultants) an up-to-date, more complete picture of a resident’s health status, allowing better management and early detection of acute illness. Use of these technologies can also promote more efficient proactive health care by directing health resources to the right individuals.”

What are we trying to achieve?

Initially the work was to focus on nursing homes for elderly people and care homes for people with learning disabilities, before progressing to residential care homes and domiciliary care settings.

These are the three main strands of work from September 2020 to March 2021:

1. Improving remote monitoring of residents in care homes

NHSX has supported care homes to increase their use of remote monitoring technologies, building on the learning and developments seen during the early months of the pandemic, helping care homes to communicate and share information about patients more easily with other care providers, such as GPs, hospitals and pharmacists. This lead to improvements in escalation planning and symptom management.

Our approach included ‘virtual ward’ approaches with care homes, using video consultation, pulse oximetry, blood pressure, temperature and RESTORE2 technologies and tools. In time we plan to extend this support to staff caring for vulnerable people with complex conditions living in their own homes.

Simon Longman, Dorset Integrated Care System and Dorset CCG, said: “Across the board remote monitoring means some face-to-face interactions between clinicians and patients are significantly reduced which saves everyone time, NHS resources and most importantly, means less upheaval for vulnerable patients. It also supports social distancing as we work to keep COVID-19 infection rates down.

“Remote monitoring can help reduce admissions to local emergency departments, means patients can be discharged faster, and people’s medicine needs are reduced, but also immediately accessible where required. These are great outcomes for patients as they don’t need to be in hospital and can stay in their own homes, which we know is better for recovery. It also means fewer GP appointments are needed, freeing up valuable doctor time for other patients and means fewer trips for often vulnerable patients who live with frailty”

2. Providing better support for people with learning disabilities 

We supported the use of remote monitoring and other digital capabilities to help people with learning disabilities manage their long-term conditions (such as diabetes, arthritis, heart or respiratory conditions) and track potential COVID-19 symptoms.

We also used these tools to increase the uptake of annual health checks (digital tools can play an important role in recording remote observations, particularly for people less able to describe how they are feeling) and improve the quality of resulting health action plans. 

We believe this will help to reduce health inequalities for people with learning disabilities, enabling them to instantly and remotely share their care needs without face-to-face contact with multiple care providers.

Sian Davies, Registered Nurse and the West of England AHSN’s Care Homes Digital Adviser, said: “If care home staff had a digital platform that would enable them to communicate more effectively with other members of the multidisciplinary team (such as pharmacists, palliative care nurses and GPs) this would save time and improve quality of care.”

You can read the full case study on the work across the region to use digital innovations to improve the health and wellbeing of people with learning disabilities on our site at FutureNHS. Alternatively email:

3. Supporting quicker, more effective clinical decision-making for the most vulnerable patients

With the needs of individual patients at the centre, we used a range of clinical communication tools to share information with health and care staff across different organisations and multi-disciplinary teams. This supported the interpretation of data coming in from remote monitoring tools, helping to ensure the right decisions are made about people’s care needs at the right time. We expect this to lead to a reduction in people needing to be admitted to emergency departments, an increase in virtual outpatient appointments, and time saving for care home staff, allowing them to spend more time on patient care.

Dr John McCormick, GP and Chief Clinical Information Officer, Devon CCG, said in 2020: “In Devon we have been using innovative, and easy to use technology to support consultation and care pathways between general practices and care homes. We have found this is a collaborative and effective system, providing flexibility within the wider system. A rapid spread of remote monitoring and along with other practical implementation to support communication and care in the South West will likely have a significant impact for patients, practitioners and communities this winter.”

Who is involved?

This programme brings together health and care organisations (both NHS and non-NHS) across the entire South West region: Devon, Cornwall, Somerset, North Somerset, Gloucestershire, South Gloucestershire, Bristol, Bath and North East Somerset, Swindon, Wiltshire and Dorset.

Partners include the seven Sustainable Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) in the South West, three Academic Health Science Networks (AHSNs) and the regional NHS England and NHS Improvement team.

These organisations have built on the great work seen during the early response to the pandemic and other ongoing digital programmes, such as Joining up Care, NHS at Home, Digital First Primary Care, and the developing One South West Local Health and Care Record (LHCR). 

Anne Pullyblank, Medical Director for the West of England AHSN, said: “We are really excited to be working alongside NHSX to support the South West region’s health and care frontline workforce to transform healthcare delivery through remote monitoring and virtual working.

“Our ambition is to enhance support to the most vulnerable and frail members of our community at this critical time. This will allow carers, healthcare professionals and citizens to quickly share vital information to enable rapid shared decision-making, leading to earlier intervention and enabling care to be delivered within the individual’s home environment.

Join the innovation collaborative

The innovation collaborative is open to all NHS, social care and local authority staff with an interest in remote monitoring. To access peer-to-peer support, guidance and tools designed to help you implement a remote monitoring service simply join our site at FutureNHS. Alternatively, please email to request to join.