Shift two: Hospital to community

By resourcing teams with improved technologies, education, skills and communications, as well as developing more integrated and streamlined pathways, the NHS can improve service delivery, care and patient outcomes, while keeping people out of hospital.

We have a strong track record here in the West of England of working collaboratively across community, primary and secondary care. We are well placed to support this ambition, which is aligned with the government’s vision to empower local teams to deliver high-quality and accessible care closer to home.

In 2024-25, examples of our support for this transformation include our HOME programme, a remote monitoring pathway designed to enhance care for people at high risk of developing hypertension during pregnancy, and the Living Well with COPD pilot, enabling people with COPD to take greater control over their health and stay well at home.

5

hospital trusts adopting the HOME pathway this year

312

clinical hours reduced in a year through use of HOME at Great Western Hospitals

234

patients enrolled in Doccla’s remote monitoring service

18%

reduction in A&E attendances amongst patients in the Living Well with COPD pilot

Supporting people at high risk of developing hypertension in pregnancy

Challenge

Hypertension affects around 8% to 10% of all pregnant women and can be associated with complications for both the mother and baby. Black and minority ethnic people are disproportionately affected, as they have an increased risk of high blood pressure in pregnancy.

People at high risk are recommended to have additional surveillance during pregnancy, usually through face-to-face appointments. This leads to additional time and travel demands on both expectant parents and healthcare professionals.

Approach

Following its success at Great Western Hospitals NHS Foundation Trust, we are supporting the rollout of HOME (HOme Monitoring for Expectant and postnatal parents) across all acute trusts in the West of England.

The HOME approach is a remote blood pressure monitoring service using a digital system and home-based monitoring equipment. This enables early detection and intervention, while reducing the need for frequent in-person visits.

Result

Based on evidence from Great Western Hospitals, the HOME monitoring pathway has demonstrated significant benefits, which we expect to be mirrored across the rest of the region. These include better care for women and their unborn babies, providing care closer to home, reducing inpatient stays and hospital admissions, reduced carbon footprint, cost and resource savings.

We also helped Gloucestershire Hospitals NHS Foundation Trust, one of the 18 Clinical Entrepreneur Programme innovation sites (or InSites) across the country, to leverage £83K of additional funding through the Greener NHS Programme to support delivery of HOME in the West of England.

This will be used to purchase blood pressure monitors and fund backfill of midwives in each trust. It will also allow us to evaluate equity of patient access, patient experience and staff impact, as well as any barriers and enablers to implementation and recommendations for spread. Being part of the InSites programme also enables us to collaborate with York Health Economics Consortium to undertake a detailed carbon and cost impact evaluation.

Read more about the HOME project here.

 

We’ve had such positive feedback from women and birthing people and hospital staff in Swindon and Wiltshire and can’t wait to see so many more people get the opportunity to benefit from this service. HOME genuinely puts the patient at the very heart of their care, while also reducing the impact on the environment and helping to make our systems more efficient.

Angela Willis Midwife at Great Western Hospitals NHS Foundation Trust

Living Well with COPD

Challenge

Chronic obstructive pulmonary disease (COPD) is one of the UK’s biggest health challenges. COPD is responsible for around 115,000 emergency hospital admissions in the UK. This is equivalent to more than one million bed days.

Approach

We supported a pilot programme in Bristol, North Somerset and South Gloucestershire called Living Well with COPD, designed to enable people with COPD to take greater control over their health and stay well at home. Working with digital partners Doccla and my mhealth, the service combined remote monitoring with health coaching and preventative care.

Result

The eight-month pilot achieved positive results, including a 34% reduction in non-elective admissions through early intervention and a 17% reduction in ambulance conveyance. Patients were impressed with the service, reporting improved confidence in self-management of their condition.

Read more about Living Well with COPD here.

I think this service is very good for me, just being able to send my details through and have someone there if I need to talk. I’m really impressed. I think this service is brilliant.

Patient involved in the Living Well with COPD pilot

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