HN’s virtual solution for diabetes and respiratory patients in Lewisham


Lewisham HCP and HN have revolutionised healthcare for diabetes and respiratory patients, through the creation of a remote Virtual Ward service delivered by telephone and an iOS/Android app, which puts patients first.

Patients were supported by a qualified nurse known as a “clinical coach”, acting as a health-educator, motivator, and healthcare -coordinator. The service has shown improved biomarkers, and high patient engagement.

The service has seen phenomenal support from Lewisham HCP clinical teams and has delivered an impressive 79% reductions in unplanned care events, creating an exciting opportunity to roll the programme out to further specialties such as cardiology.

The problem

According to Public Health England, diabetes costs the NHS £9.8 billion per year – and the prevalence is rising. Around 300,000 people live in Lewisham in south-east London, with about 15,000 recorded cases of diabetes and approximately 8,000 people estimated to be living with undiagnosed Type 2 diabetes. COPD is the third leading cause of disease burden In Lewisham. It is the third leading cause of death among males and the eighth among females. Projections show increases in COPD and diabetes over time.

To resolve this inequality and improve outcomes in diabetes and respiratory amid the covid crisis, Lewisham Health and Care Partners sought a technology partner to create a service facilitating early supported discharge in order to release acute capacity. The service was be a remote digital monitoring service aimed at avoiding unnecessary non-elective admissions and A&E attendances.

The overall aim of the service was to empower patients to self-manage, improving their outcomes and preventing unnecessary hospitalisation, and mitigate pressures in community-based services for this cohort of patients with long-term conditions.

HN were commissioned to develop this new virtual ward technology product based around Lewisham HCP’s requirements, and to deliver their scientifically evidenced clinical health coaching service.


In Lewisham there were problems with acute capacity, which created a need for patients to be monitored outside of the hospital setting, with safe management at home. The Lewisham area also has significant inequalities which the partnership saw technology in a home setting as a solution to – this project was to be a test to explore the safety and efficacy of virtual ward technology.

Lewisham HCP noticed a significant correlation between digital inequality and social inequality, and addressing this was to be a key element of the service. To compensate for digital inequalities, the technology has two levels of care available depending on the tech-literacy of the patient:

  • Level 1, is for those who can use a smartphone, allowing patients to input their biomarkers into a mobile phone app.
  • Level 2, has more frequent calls from the health coach to take the biomarker results and input them into the system.

The technology was entirely built around Lewisham HCP’s requirements and was a newly designed HN product based around the concept of a virtual ward.

HN virtual ward

Every HN coach is a qualified healthcare professional, and, for this service, all coaches were qualified registered nurses. All coaches are trained through HN’s in-house training programme which is accredited by NHS England’s Personalised Care Institute. The coaches involved in this programme received extra training in use of the virtual ward and were chosen based on their experience of the two specialties involved. As qualified nurses, the health coaches were experienced in the management of diabetes and COPD. With the restrictions of the pandemic, this was all conducted remotely.

The technology was delivered direct to patients, not mediated by the referring organisation. To introduce the technology to patients, the coaches explained the technology to patients and provided details of tech support where necessary. The service met all of Lewisham’s requirements and exceeded expectations in delivering:

  • a 79% reduction in A&E attendances and NEL admissions for diabetes patients
  • a 50% reduction in A&E attendances and NEL admissions for respiratory patients

Growing the service to 300 patients, would prevent 259 A&Es, 225 NELs, 1081 bed days, and deliver a financial saving of £1,004,872.

"There is a considerable time pressure in clinical consultations, with a limited ability to address the many and different unresolved issues people have in their day to day lives. HN have met this."- Quote from clinician involved in the programme.

Beyond Lewisham

The new “Navigator” technology developed as part of this project has been incorporated into other HN projects with NHS partners, with HN expanding into other sites and primary care.

Improved diabetes care and CVD prevention is a key aspect of our approach to helping people across south-east London stay health and well.

The technology partnership has added immense value to the NHS organisations involved. The technology has supported earlier safe discharge, releasing crucial extra hospital capacity during the covid crisis. The technology created new self-management capability with its patients and prevented avoidable admissions.

The health economic impact is underway with several senior clinicians noting that patients onboarded to the virtual ward would have likely become high intensity users of primary and secondary care in the upcoming year were it not for the service. Furthermore, this intervention has gone beyond the typical NHS contract reporting processes and has analysed and demonstrated improvement in clinical outcomes.

For staff, the service has led to noticeably reduced case-loads. The service took on 30 of the highest-consuming patients, and helped support them to live well at home, avoiding the need for NHS appointments. Staff have noticed a reduction in attendances from these patients, and are assured these patients are being monitored and cared for outside the normal service.

For patients, the return has been predominantly in improved health. The high levels of engagement will only serve to improve these patients’ lives through long term improved engagement with their healthcare.

The process has significantly improved discharge by making it safer and quicker. Clinicians now have confidence that patients are being monitored by a dedicated healthcare professional via technology at home.

Now, patient exacerbations are identified and managed locally in the community, not at hospital. The reduction in primary and secondary care contacts have led to resources being freed up in the system, which can be used for patients in immediate need.

The evidence to date shows that patients can be discharged after 3-4 months, rather than the 6 months that patients were in the virtual ward pilot study. This has allowed the capacity of the virtual ward to be increased, enhancing capacity to support more patients in the intervention, and reducing per patient costs from approximately £2,800 to £1,623 (as 80% of the cost was due to staffing).

Our virtual ward brings care into people’s home. This, combined with the personalised support of a clinical coach, embeds self-care capabilities. The workstream will be a key part of our existing transformation and recovery programme and will be supported by our existing programme delivery and operational resources.

Lewisham HCP have established a strong population health driven approach and the partners have invested significantly in Lewisham’s integrated data and information management system. The system enables areas for transformation and improvement to be identified and analysis of population level data informs and validate the decisions being taken. This system enables not just the identification of patients but can model the impact of interventions to support them, using a positively evaluated remote model.

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