What Does 'Good' Look Like? Remote Monitoring for Healthcare

Adrian Flowerday says: ‘The recent report by Lord Darzi states: 'the NHS is 15 years behind the private sector in its use of technology' and that the NHS is in the ‘foothills of digital transformation’.  It’s no secret that the health and care sector is facing significant challenges: with record-high waiting lists, a rising demand for services, declining satisfaction levels, a workforce facing significant strain, overwhelmed primary care services and the added impact of winter pressures.

According to other reports, failures in resourcing significantly impact the NHS during critical periods, leaving patients without timely care.  Recent research also highlights that GPs devote over a third of their time to patients who have three or more serious chronic conditions – which represents 16 percent of the population. 

Solutions are needed to manage demand more effectively, especially among vulnerable populations like the elderly, frail, those with long-term conditions and those facing poverty. 

The recent Tony Blair Institute report ‘Preparing the NHS for the AI era’ states that “Investment in the country’s digital and data infrastructure may seem like a second-order consideration at a time when elective waiting lists stand at more than 7 million– but without it, long waits and care failures will continue”.

Lord Darzi also recommends moving from ‘diagnose and treat’ to ‘predict and prevent’, as well as a ‘major tilt towards technology to unlock productivity.’

To mitigate this, a proactive approach is required—one that addresses the root cause of preventable hospitalisations and A&E visits. Too many patients end up in hospital needlessly. We have long advocated for the effective use of remote monitoring and virtual care to support clinicians, enhance patient outcomes and provide proactive care. 

A proven strategy is to invest in remote patient monitoring at scale, a solution that has already shown impressive results in reducing ambulance callouts, hospital A&E pressures and admissions and easing GP workloads. But how do we scale? How do we identify the right patients? How do we afford it?

Population health and remote monitoring: a proven approach

By seamlessly combining population health and remote monitoring, identification of cohorts suitable for remote monitoring is available at the click of a button - with identified cohorts of patients automatically enrolled onto the remote monitoring solution. Tracking enrolled cohorts against similar cohorts in population health allows real world evaluation of outcomes and subsequent economic savings. For example, the Frimley Health and Care Integrated Care System (ICS) has demonstrated how combining intelligent precision identification of cohorts who then receive remote monitoring, can significantly reduce hospital admissions by up to 40% for high-risk complex patients, such as those suffering from heart failure, diabetes, and COPD. Over 10,000 patients are being monitored daily, while care home residents enrolled in the programme experienced a 34% reduction in hospital admissions, a 31% reduction in A&E visits and a 20% drop in GP contacts and a huge 70% reduction in length of stay. 

But how do we afford it?  An independent actuarial report on the Frimley work by Strategia and Imperial College showed a net saving in the order of £5m-£7m, which does not include wider savings such as the reduction in the cost of treatments and procedures.   

Going back to the Tony Blair Institute report , the writers talk about Frimley and Cheshire and Merseyside, two clients of Docobo and Graphnet:  ‘Led by Frimley Health and Care ICS and Cheshire and Merseyside ICS, 11 ICSs covering 17 million patients operate the system and work together. CIPHA (Combined Intelligence for Population Health Action) uses the data, analytics and associated tools to provide insights for service transformation in areas such as the management of patients with long-term conditions (LTCs), support for patients in care homes, prevention programmes (covering the likes of strokes, fuel poverty and diabetes) and the management of waiting lists. With its rich dataset in Graphnet’s Shared Care Record driving the Population Health dashboards, CIPHA can provide those ICSs with a comprehensive understanding of the risk profile of their populations, which enables them to plan services accordingly. CIPHA includes patient access in some ICSs, including the ability to upload home-monitored data such as blood pressure and weight, as well as ECGs. In some cases, it also feeds patient-level insights back to clinicians in primary care.’ 

Reducing the Burden on Primary Care

Remote monitoring doesn’t only reduce pressure on hospitals but also on GP services, where it is really needed. In Bexley, for instance, GP demand decreased by up to 19% for high-need patients, illustrating the potential of these technologies to manage long-term conditions more effectively. Patients enrolled in these remote monitoring programmes are identified using population health data, enabling healthcare providers to proactively intervene before patients experience serious deterioration.

Use of population health to perform precision cohorting is key to the success of interventions.  Take a look at the recent work carried out by Cheshire & Merseyside, who have used population health tools to support those most at risk of fuel poverty.  Graphnet developed a fuel poverty dashboard in CIPHA, which draws health and social care information on 2.6 million Cheshire and Merseyside residents from all parts of the care system. 

The results have been impressive. Diane Green, community respiratory nurse at Mersey and West Lancashire Teaching Hospital, and lead COPD nurse for the St Helens Community COPD Rapid Response says: ‘Through the Graphnet fuel poverty dashboard, we’ve been able to identify patients in need and target them in a completely different way. This is truly integrated, holistic nursing care. We use the Johns Hopkins algorithm to drill down and find patients that are in quintile one for deprivation and quintile one for poverty, but also those that have had the highest admissions over the past 12 months and diagnosed with COPD.’

Building on success

Remote monitoring solutions, such as the Docobo remote monitoring platform, allow patients to submit vital health data from the comfort of their homes, giving healthcare professionals real-time access to critical information. When coupled with population health tools from Graphnet, this approach not only improves patient outcomes but also optimizes healthcare resources. With over 10,000 patients onboarded in the Frimley region alone, the initiative has proven scalable, offering a blueprint for nationwide deployment There are also excellent examples of where Docobo remote monitoring and virtual care is being used to tackle specific areas of the population – such as in Dudley with supporting children with virtual care; Liverpool University Hospital tracking patients waiting for heart surgery; and at the Medical University in Vienna to support cancer patients at home. 

A path forward for the NHS

The significant impact of anxiety, depression and other mental health issues on patients with long-term conditions (LTCs) also drives the increased demand on GPs. Our many years providing Docobo remote monitoring to manage LTCs like COPD and CHF has shown that remote monitoring not only boosts patient confidence and satisfaction but also reduces anxiety and depression, with a correlated reduction in service demand, emergency callouts and hospital admissions. 

Scaling up remote monitoring can provide the NHS with a powerful tool to reduce winter pressures and improve patient outcomes through proactive prevention. By focusing on the most vulnerable populations, the NHS can take a proactive stance, preventing unnecessary hospital admissions and allowing healthcare professionals to manage patient care more efficiently. Investing in these technologies is essential not just for mitigating seasonal demand but for building a more resilient and responsive healthcare system.

Using the Graphnet and Docobo remote monitoring approach you can identify cohorts of patients who require proactive support, break down barriers between healthcare organisations with seamless case management, ensure the entire care team has access to pertinent information, facilitate online interaction between patients and clinicians, and implement remote monitoring technology for continuous care in the comfort of patients’ homes.

By integrating remote monitoring and population health into everyday practice, the NHS can move from reactive care to a more proactive, data-driven model -  from ‘diagnose and treat’ to ‘predict and prevent’ - reducing the burden on both hospitals and GP services while empowering patients to manage their conditions more effectively.'

Get in touch today discuss how Graphnet solutions can support your organisation’s remote monitoring and population health analytics.