People who regularly need urgent or emergency NHS care are hailing a ground-breaking initiative, which has reduced attendance at A&E by 70 per cent for some patients with complex health conditions.
Hospitals, GPs and other health and care services in east Kent have worked together to identify people who most frequently use accident and emergency departments or walk-in centres, to see if they could be helped to manage their health at home.
The East Kent Health and Care Partnership (EKHCP) led the efforts, focusing on patients living in east Kent who were frail and living with complex health needs. They used advanced data analytics to see who would benefit most from taking part, along with Graphnet Remote Monitoring, to support people to better manage their health themselves at home and to avoid unnecessary hospital visits.
Patients were given access to Graphnet Remote Monitoring, a digital service that captures a range of health metrics from home. The system was particularly focused on complex frail patients and those living with COPD. Using a simple app, patients recorded daily health data such as oxygen levels, blood pressure, heart rate, or symptom questions. These readings were automatically transmitted to a central digital hub, where the data was triaged and alerts were managed in real time.
When required, escalations were sent directly to the patient’s GP or other relevant clinician. This meant the hub could handle routine monitoring and only involve GPs when additional support was needed, reducing demand on primary care. The proactive nature of the service allowed potential problems to be spotted early, meaning patients received timely interventions that reduced the risk of deterioration and avoided unnecessary trips to the GP or emergency department.
The trial has seen outstanding results, showcasing how the NHS is using digital innovation to support vulnerable patients at home and reduce pressure on hospitals. After taking part in the trial, patients reported reduced anxiety, greater confidence in managing their health and feeling better supported to stay well at home.
The trial saw:
- 69 per cent reduction in emergency department visits
- 68.4 per cent reduction in walk-in centre visits
- 70 per cent reduction in emergency hospital admissions for the cohort
Dr Sarah Phillips, Chief Medical Officer at Kent Community Health NHS Foundation Trust, Senior Lead for the pilot and Chair of the Programme Board, said:
“When we looked at the data, we discovered just three per cent of east Kent residents accounted for nearly 12 per cent of all accident and emergency (A&E) department attendances and 18.5 per cent of emergency admissions.
“Of these, around 500 patients were invited to take part in a trial, which helped support them to monitor their health, using simple technology at home.
“We are delighted with the results. This approach not only makes patients feel more in control of their wellbeing, but also proactively keeps people out of hospital and in the community, allowing them to be cared for in the comfort of their own homes, where they recover faster. It also shows how using digital tools can lead to powerful improvements in care - keeping people well and bringing services closer to home.”
Patients also welcomed remote health monitoring. A husband, whose wife was enrolled in the trial, said: “I think the service is brilliant and I’ve told my GP this too. My wife has been in nursing for 45 years and if she thinks it is good, then it is! My GP has also praised it.”
The trial involved using the combined intelligence for population health action (CIPHA) programme, which uses data from many sources to give a comprehensive view of health trends, enabling healthcare providers to work together to proactively intervene to prevent ill-health.
