People often think the NHS is under pressure because of a lack of capacity. In reality, the challenge is the system itself, fuelled by demographic change, rising demand and increasingly complex patient needs.

Markus Bolton, Executive Director at Graphnet Health spoke on our YouTube channel about these very challenges. 

He said: “Patients are living longer, with more long-term conditions, and the result of that is a massive increase of pressure on the health service.”

Despite this, much of the system is still organised around acute, reactive care. Hospitals are being asked to absorb levels of demand they were not designed to manage indefinitely.

Virtual wards, hospital-at-home models and remote monitoring all have an important role to play in moving care closer to home. But if they are treated as pilot programmes, used in isolation or viewed as standalone digital tools, their impact will always be limited.

The bigger opportunity is to use connected data, monitoring and population health insight to identify people at risk, intervene earlier and prevent avoidable deterioration before hospital care is needed.

The NHS cannot solve a continuous-care problem with an episodic-care model

An episodic care model is difficult to sustain for people living with long-term health conditions. For these patients, risk builds gradually, symptoms change and support needs can shift over weeks, months or years.

It’s also not uncommon for patients to move between primary care, community services, urgent care, hospital services and social care, often with different professionals involved at different points.

If demand continues to rise while the system remains primarily reactive, the NHS will keep being forced to respond after a person’s condition has already worsened.

As Bolton puts it: “We can see attendance going up by a couple of percent per annum and at that level the acute service can no longer deal with the amount of activity that’s required.”

A sustainable approach depends on shifting more of that effort upstream. This means supporting people before they reach crisis point, helping them manage their conditions with confidence and giving care teams the information they need to act sooner.

Why pilots rarely create the evidence or confidence needed for change

One of the biggest barriers to meaningful digital transformation in the NHS is the failure to move beyond small-scale pilots.

As Bolton says: “It’s all very well piloting something just to make sure that the mechanics work, but you’re never going to get the results that you want with small level programmes because you just don’t have enough support from the wider service to make those happen.”

This really matters for remote monitoring. A small pilot might show promise, but it might not involve enough people to prove impact across a population, or enough services to embed a different way of working. With a small sample, it becomes harder to produce results the wider system can act on, and harder to build confidence among decision-makers.

Bolton makes this point clearly: “If you take 10,000 patients and push them through it then the statistics that come out are totally compelling. If you take 500 patients and push them through a programme, it’s much more difficult to see the impact that that has.”

Graphnet’s own remote monitoring work reflects this shift from isolated projects to scaled implementation, with its platform now supporting 84 live clinical pathways across 16 NHS organisations and more than 2.2 million patient measurements submitted.

This is the kind of scale that’s needed if remote monitoring is to move from promising innovation to mainstream care delivery.

Hospital to home should not stop at virtual wards

Virtual wards and hospital-at-home models have shown that more care can be delivered safely outside hospital. They can support earlier discharge, help free up beds and give patients the reassurance of being monitored at home.

However, the biggest value of remote monitoring isn’t short-term discharge support. It’s the ongoing management of long-term conditions.

Bolton explains how short-term virtual ward pathways often require patients to be enrolled, issued with equipment, shown how to use it and then stepped down again soon afterwards. For a relatively brief period of monitoring, that can create a significant amount of administration.

Long-term condition monitoring works differently. Patients may stay on a programme for months or years, with the ability to step care up or down as needs change. The equipment, education and pathway setup can then support ongoing care, rather than a single episode after discharge.

Used only as a hospital-to-home tool, remote monitoring is limited to one point in the pathway. Used as part of a longer-term approach, it can help people stay well, support self-management and spot signs of deterioration before hospital care is needed.

Remote monitoring only works as part of the continuum of care

Remote monitoring can help patients understand their condition, build confidence in self-management and feel reassured that someone is keeping an eye on their health. It can also help care teams identify deterioration earlier and escalate support when more help is needed. But it cannot work in isolation. As Bolton puts it: “Remote monitoring is part of a wider package of care for a patient.”

A person may need advice from primary care, support from community services, input from emergency services or treatment from a hospital team. If monitoring sits outside those pathways, it risks becoming another disconnected system, rather than part of joined-up care around the patient.

This is where shared care records, population health intelligence and remote monitoring need to work together. Clinicians and care teams need a joined-up view of the patient. Monitoring data needs to be meaningful and actionable. Escalation routes need to be clear. And patients need to know what is expected of them and what to do if their readings or symptoms change.

Prevention is becoming a data problem the NHS can actually solve

For years, prevention has been one of the NHS’s most important ambitions, but it’s also one of its hardest to deliver. The service has often had to act when a patient presents in crisis, rather than when their risk first begins to rise. Better data is making earlier intervention more achievable.

“The key now is that we have the data and the analytics required to predict deterioration before it happens,” says Bolton.

By bringing together data from across care settings, including NHS 111, 999 services, hospitals, GPs, social care and community care, health and care systems can start to identify the people most likely to deteriorate, attend A&E or need admission.

The picture becomes even clearer when clinical insight is combined with other datasets, such as housing, energy efficiency or economic indicators. For example, respiratory risk in a household may look very different when it is viewed alongside information about the condition of the property, heating challenges or financial pressure.

This is the real promise of preventative care: using insight to understand who needs support, when they need it and where resources can make the greatest impact.

What good looks like for ICSs

For Integrated Care Systems, success over the next three to five years will not be measured by the number of digital tools deployed or the number of pilots launched. It will be measured by whether they can bring demand back within a level the system can manage.

As Bolton says: “What I see the good looks like is that we have enough patients being managed, either being encouraged to self-manage or through remote patient monitoring, where we stop that increase.”

For ICSs, this is where data starts to support more targeted prevention. It can help teams understand not only who may be at risk, but what kind of intervention is most likely to make a difference.

That means moving beyond fragmented programmes and building scaled, connected approaches that are embedded across pathways. Remote monitoring needs to link into shared care records, data dashboards and clear escalation routes, so teams can understand who is at risk, what support they need and where intervention is most likely to make a difference.

That is what sustainable care looks like in practice: more people supported safely at home, more patients able to manage their conditions with confidence and more deterioration prevented before it becomes an emergency.

The next step: scaled, preventative care

Hospital to home is an important part of the shift towards more sustainable care. But on its own, it does not answer the wider challenge facing the NHS.

The real opportunity is to use remote monitoring, shared care records and data-led insight to support people earlier, manage long-term conditions more effectively and prevent avoidable deterioration before hospital care is needed.

That requires more than another small pilot or standalone digital pathway. It requires scaled, connected models of care that give teams the confidence, evidence and visibility to act sooner.

For ICSs, the goal is not simply to move care out of hospital. It is to reduce the need for hospital care in the first place.

At Graphnet Health, we help health and care systems bring together remote monitoring, shared care systems and population health insight to support more proactive, preventative care at scale. 

Contact our team to learn more.