Redesign and scaled deployment of service to support chronic obstructive pulmonary disease (COPD) patient to self-care with digital technology.
To respond to the challenge of increasing demand for health services (within static resources), NHS Liverpool Clinical Commissioning Group redesigned a community COPD service. Under-pining redesign is technology to improve education and information to enable patients to self-care and manage their condition with remote monitoring.

Partnering with NHS services, third sector organisations and industry, NHS Liverpool CCG has scaled this service to support over 10,000 patients. At any one time c1000 patients are supported by the service.

Utilising clinical patient telemetry to deliver ‘intelligence led healthcare’ has resulted in reductions in emergency admissions and secondary care costs of between 22% and 32%. And this model uses scarce clinical resources more efficiently 1 nurse supporting 200 patients (compared to 1 nurse supporting 35 patients in the existing service model)

NHS LCCG and a new supplier of the technology element of this service are planning to extend the range of conditions supported (to include e.g. patients with heart failure, asthma, cancer), to patients with a higher level of need (to speed hospital discharge) and to increase the number of citizens activated.

Key stakeholders include:
• Mersey Care NHS Trust (Clinical Hub provider)
• Primary care practitioners inc. general practitioners (GPs)
• Citizens/patients
• Technology providers (Docobo and Florence)
• Civil society partners inc. PSS

Resources needed

Oct 2012-Sept 2015 Redesign & Scaling Phase = £2.05m capital and revenue from NHS Liverpool CCG + Innovate UK. Project team consisted of Programme Director, 2 Senior Programme Managers, Administration Manager, 2 service designers + staff from 7 sub-contrators
Oct 2015 Operational Phase = £2m pa

Evidence of success

c10,000 patients have been supported to date and c1,000 patients are supported at any one time.
90% of patients feel more in control, have gained confidence &/or feel better able to cope with their condition
52% of patients report improved lifestyle & 79% improved health or better health management
Reduction in emergency admissions & secondary care costs in comparison with a control group ranging from 22-32%
Nursing/patient ratio reduced from 1:35 to 1:200

Difficulties encountered

Our GP demonstrates that self-care in health can have a positive impact upon patient well-being. Technology is an enabler/accelerator, a tool to support preventative approaches to well-being.
There is however a non-interoperatability between self-care and standard health operating models

Potential for learning or transfer

One of the largest, mainstreamed technology supported services in Europe for a single health economy. This Good Practice has:
1. patient scaled self-care, enhanced current service offer and integrated technology rather than focusing solely upon scaling technology through service design.
2. secured clinical engagement across health partners and through governance and operational levels, creating innovative solutions to evidence gathering
3. engaged smartly with citizens through the things they like and need to do (as “health” is a really difficult sell)

The reader should note that:
a) this GP may be system specific and require tailoring for export/import
b) although positive impact (reported above) adds much needed service capacity it rarely results in savings. High service demand means that for every person moved in to the new service model, there are many more to take their place in the old service model.

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Main institution
Liverpool City Region LEP
Merseyside, United Kingdom
Start Date
October 2015
End Date


Paul Clitheroe Please login to contact the author.