Mersey Care and Cheshire and Merseyside: Using Population Health Intelligence and Remote Monitoring to Deliver proactive Care at Scale

At a Glance

Organisation: Mersey Care NHS Foundation Trust

Region: Cheshire and Merseyside

Solution: Graphnet Population Health Management and Remote Monitoring

Focus: Long-term condition management, virtual wards, preventative care and neighbourhood health

Key Outcomes:

•    28% reduction in A&E attendances
•    36% reduction in emergency admissions
•    34% reduction in GP encounters
•    Reductions in outpatient appointments and elective admissions
•    Improved patient confidence, self-management and health outcomes
•    Scalable model supporting ambitions to increase monitoring from 2,350 to 10,000 patients per day

Why This Matters

Many NHS organisations are exploring how remote monitoring can support neighbourhood health, reduce pressure on frontline services and improve outcomes for people living with long-term conditions.

Mersey Care's experience demonstrates how combining population health intelligence with remote monitoring can help identify the right patients, intervene earlier and deliver measurable improvements at scale.

The Challenge

Across Cheshire and Merseyside, increasing numbers of people are living with complex long-term conditions such as COPD, heart failure and diabetes.

At the same time, NHS organisations continue to face growing demand, workforce pressures and financial constraints. Traditional models of care often rely on patients seeking help when their condition deteriorates, leading to increased pressure on GP services, urgent care and hospitals.

Mersey Care recognised that delivering more proactive, preventative care would require a different approach. The organisation wanted to identify patients at risk earlier, support them in managing their conditions at home and reduce avoidable hospital activity through timely intervention.

The challenge was not simply introducing remote monitoring technology. It was ensuring that the right patients were identified, enrolled and supported in a way that delivered meaningful outcomes.

Building a Scalable Telehealth Service

Mersey Care began its remote monitoring journey more than a decade ago, initially supporting patients with long-term conditions including COPD, heart failure and diabetes. Over time, the service evolved into a dedicated telehealth hub supporting patients across Cheshire and Merseyside. Today, the hub supports long-term condition management, virtual wards and a range of community-based pathways through a single operational model.

Around 56 whole-time equivalent staff work within the service, providing monitoring, clinical review, education and coaching for patients across multiple pathways.

The model has been deliberately designed to be flexible, allowing patients to move between different levels of monitoring depending on their needs. Patients can receive intensive clinical monitoring, light-touch support or self-directed monitoring, ensuring resources are focused where they can deliver the greatest value.

Identifying the Patients Most Likely to Benefit

One of the biggest challenges facing remote monitoring programmes is identifying the patients who will benefit most from intervention.

Historically, this process involved reviewing GP registers, prevalence data and risk stratification information from multiple systems. The approach was labour intensive and difficult to scale consistently across a large geography.

To address this challenge, Mersey Care began using Graphnet's population health management platform to identify patients based on risk, need and likely benefit.

Using risk stratification tools and predictive analytics, the organisation can proactively identify patients at increased risk of deterioration or emergency admission and target support accordingly. This approach enables clinicians to focus resources where they are most likely to have an impact while ensuring patients receive support before a crisis occurs.

The population health platform also enables the organisation to understand local variation and target interventions at place and neighbourhood level, supporting broader integrated care objectives.

Customer Perspective

"Using the population health data enables us to identify the cohorts of patients that we know will benefit the most from telehealth."

Peter Almond, Head of Service for Digital and Administration, Mersey Care NHS Foundation Trust

Supporting Patients Beyond Traditional Healthcare Settings

Once enrolled, patients are supported through a remote monitoring service delivered through the Graphnet Remote Monitoring platform, powered by Luscii. 

Patients submit physiological observations, symptoms and wellbeing information from their own homes. Depending on their condition, this may include measurements such as blood pressure, oxygen saturation, weight and other clinical indicators.

This information is reviewed by the telehealth team and prioritised according to clinical need, allowing early signs of deterioration to be identified and addressed before patients require urgent or emergency care.

However, monitoring is only one part of the service. Patients also receive education, coaching and support to help them better understand and manage their conditions. This helps improve confidence, supports self-care and encourages healthier behaviours that can contribute to better long-term outcomes.

Customer Persepctive

"We've got a better view of those patients. We can identify early deterioration and prioritise those patients for care."

Peter Almond, Head of Service for Digital and Administration, Mersey Care NHS Foundation Trust

Delivering Measurable Outcomes

The combination of population health intelligence and targeted remote monitoring has delivered significant benefits across Cheshire and Merseyside.

Mersey Care reported:

•    28% reduction in A&E attendances
•    36% reduction in emergency admissions
•    34% reduction in GP encounters
•    Reduced outpatient activity
•    Reduced elective admissions
•    Reduced prescribing activity

The service has also generated strong patient-reported outcomes.

Patients reported greater confidence in managing their own health, improved understanding of their conditions and increased motivation to make positive lifestyle changes. Many also reported improvements in their overall health and wellbeing.

The benefits extended beyond individual patients, with family members and carers also reporting positive impacts from knowing that their loved ones were being actively supported.

These outcomes build on earlier evidence published in the BMJ, which demonstrated a 25.3% reduction in emergency admissions among telehealth patients. The organisation is now working with the University of Liverpool on further evaluation to understand the full impact of the service.

The programme has also received national recognition. As part of Liverpool Place Population Management, it contributed to the Neighbourhood Health Award at the NHS Excellence Awards 2026. Judges praised the initiative as a "working, city-scale example" of neighbourhood health in practice, recognising its innovative use of population health management to identify people at greatest risk and deliver coordinated, preventative care.

Supporting the Future of Neighbourhood Health

As the NHS continues to develop neighbourhood health models, Mersey Care believes remote monitoring will play an increasingly important role in supporting care closer to home.

By combining population health intelligence with remote monitoring, the organisation can proactively identify risk, support earlier intervention and reduce reliance on hospital-based services. This approach aligns closely with national priorities around prevention, proactive care and integrated service delivery, while helping clinicians focus resources on patients with the greatest need.

The organisation is now exploring how the model can be expanded further across Cheshire and Merseyside, with the longer-term ambition of supporting more care in the community and reducing reliance on hospital services.

Customer Perspective

"If we were doing this at scale with 10,000 patients per day, that's when we start to get into the space of reconfiguring services and reducing reliance on hospital-based care, alongside having a real tangible impact on the number of patients attending A&E."

Peter Almond, Head of Service for Digital and Administration, Mersey Care NHS Foundation Trust

Conclusion

Mersey Care's experience demonstrates that remote monitoring delivers the greatest value when it forms part of a wider population health strategy.

By combining Graphnet's population health management capabilities with remote monitoring, the organisation has created a proactive model of care that identifies risk earlier, supports patients in their own homes and delivers measurable improvements across the healthcare system.

The results show how integrated population health and remote monitoring solutions can help health and care systems improve outcomes, reduce demand and support the delivery of neighbourhood health at scale.