Remote care

Without active monitoring, people with diabetes are at risk of:

• deteriorating eye health
• poor kidney function
• cyclical vomiting syndrome

We partnered with an analytics company to develop an algorithm using data from 4,000 patients on our diabetes follow-up waiting list. It found that:

• 16% of patients were high risk, prompting the service to bring forward their planned future appointment
• 9% were low risk and suitable for alternative pathways, such as patient-initiated follow-up and virtual consultations, or could have their appointment later than planned

Early analysis of the high-risk patients indicates they are disproportionately from minority ethnic groups and lower socio-economic backgrounds. This data-led approach:

• makes sure we see people when they need it
• reduces systemic inequalities in access to healthcare

Following a successful pilot in the diabetes service, the tool will be adapted for other services such as rheumatology, kidney, cardiology and eye (ophthalmology).

Rheumatoid arthritis is a long-term, inflammatory joint disease. Without the right treatment, persistent flare-ups can lead to joint damage and disability.

Our remote monitoring service has 4 steps.

1. Patients or their carers are sent an online questionnaire every 4 weeks.
2. A digital pathway coordinator reviews the data.
3. They tell a clinician if their patient has reported increased symptoms.

4. This information helps to decide if the patient needs a face-to-face or telephone appointment, or if they can receive advice remotely.

Early findings show high patient participation with 87.6% engaging with the service. 77.5% had their rheumatoid arthritis flare-up identified early. This changed how they were managed and possibly reduced the number of hospital appointments. 

The approach is now being introduced across south east London, supported by the Health Innovation Network.