Evaluating remote monitoring in primary care to improve outcomes for people with long-term conditions

For people living with long-term conditions such as type 2 diabetes, respiratory disease and heart failure, managing their health can be complex and time-consuming. Regular monitoring, appointments and tests are essential, but this often places strain on both patients and primary and emergency care services. 

Leeds Integrated Digital Service (supporting NHS West Yorkshire Integrated Care Board and Leeds City Council) wanted to explore how digital innovation could ease this burden and improve outcomes. With funding from NHS England, the team piloted a new approach using Luscii remote monitoring technology within two Primary Care Networks in Leeds.

The goal was simple but ambitious — to redesign pathways so that patients could monitor their own health more effectively, access care when they needed it, and help clinicians focus their time and resources. 

Health Innovation Yorkshire & Humber was asked to provide an independent evaluation to understand the real-world impact of the pilot. 

Our team used a mixed-methods approach, combining data analysis with insights from interviews conducted with patients, clinicians and project stakeholders. We reviewed healthcare utilisation across primary and secondary care systems (SystmOne, EMIS and hospital data) to measure changes in appointments, emergency attendances and admissions. We also captured patient-reported outcomes through wellbeing questionnaires and in-depth interviews, exploring confidence, empowerment and ease of use. 

By engaging closely with the Leeds partners throughout the pilot, we ensured that learning was shared in real time and informed decisions about what worked best and why. 

The findings showed that remote monitoring can make a real difference for both patients and the system: 

• 80% of patients had fewer unplanned inpatient attendances related to their monitored conditions. 
• 47% had fewer A&E visits, with another 27% showing no increase. 
• Patients reported feeling more confident managing their health and more in control of their conditions. 
• Clinicians viewed the service as scalable, sustainable and supportive of more effective use of workforce capacity. 

The evaluation findings and recommendations for scaling have already influenced next steps. Leeds City Council and NHS West Yorkshire ICB have applied for additional funding to expand the pilot, and the work is helping to shape the Leeds Tech-Enabled Care Strategy.  

Our recommendations focused on how this successful approach could be scaled across Leeds and beyond: 

• Establish a centralised remote monitoring hub to maximise workforce efficiency and consistency. 
• Communicate clearly with patients and staff from the outset about the pathway, benefits and roles. 
• Involve a broad range of stakeholders when selecting technology, ensuring interoperability with Electronic Patient Records (EPRs). 
• Streamline processes for identifying patients suitable for remote monitoring. 

These lessons are helping teams across Leeds design a model that can be adopted more widely to support people with long-term conditions and reduce demand on frontline care. 

This work supports the NHS long-term ambition to deliver more proactive, personalised care for people with long-term conditions.  

By generating independent evidence and actionable insights, Health Innovation Yorkshire & Humber has helped partners in Leeds demonstrate how digital innovation can empower patients, improve outcomes, and reduce pressure on urgent and emergency care and primary care.

Interested to learn more?
Discover how Health Innovation Yorkshire & Humber can help your organisation evaluate digital innovation, generate real-world evidence, and scale solutions that improve outcomes for patients and the workforce.