A&E attendances are down by 28 per cent and GP encounters by 34 per cent, demonstrating how proactive, community-based care can improve outcomes for people living with long-term conditions while reducing pressure on NHS services.
The programme forms part of the Liverpool Place Population Management model, which won the Neighbourhood Health Award at the NHS Excellence Awards 2026. Judges described the initiative as a ‘working, city-scale example” of the neighbourhood health model set out in the NHS 10 Year Health Plan, recognising its innovative use of linked health and care data to identify people most at risk of deteriorating health and provide coordinated support before they reach crisis point.
Delivered by Mersey Care NHS Foundation Trust, the telehealth service supports people living with long-term conditions including COPD, heart failure, and diabetes. By combining proactive case finding with remote monitoring, the programme enables clinicians to identify patients who are most likely to benefit from additional support, helping them manage their conditions at home and reducing the likelihood of avoidable hospital admissions.
Peter Almond, head of service for digital and administration at Mersey Care NHS Foundation Trust, said: “Using the population health data enables us to identify the cohorts of patients that we know will benefit the most from telehealth. We’ve got a better view of those patients. We can identify early deterioration and prioritise those patients for care.”