Long term conditions early intervention programme

‘Harnessing information, analytics and technology to support Proactive and Preventative care delivery within NHS Heywood, Middleton and Rochdale’

Who is involved?

The collaboration between NHS Heywood Middleton and Rochdale (HMR) CCG, MSD and Verily Life Sciences brings together world class clinical, scientific, and analytical capability together with innovative technology to address healthcare challenges. The collaboration will include developing solutions that will combine data analytics with tele-health, tele-care and tele-treatment to target more effective management of Long Term Conditions (LTCs).

Patient population size

The initial phase of our Test Bed programme will focus on citizens considered at moderate and high risk of developing or with with LTCs, within HMR CCG. This will then be rolled out to a minimum of 5 Greater Manchester CCGs within 2 years covering a population of 1 million people.


Approximately 15 million people in England are living with long-term conditions (LTCs) such as cardiovascular disease, coronary obstructive pulmonary disorder (COPD) (some lung diseases) and asthma.

LTCs are one of the main drivers of cost and activity in the NHS and now account for about 50% of all GP appointments, 64% of all outpatient appointments and over 70% of inpatient bed days1.

Identifying a significantly ‘at risk’ individual just one year earlier than at present can radically reduce their chances of developing future ill health.

The HMR CCG, MSD, a trade name of Merck & Co., Inc., with headquarters in Kenilworth, NJ, USA, and Verily Life Sciences Test Bed programme seeks to help combat this problem with the development of a tool combining data analytics with a telehealth service for managing patients at risk of developing LTCs and designed to help medical professionals better predict who may be at risk.

We believe that by understanding how a patient’s environment, access and engagement with healthcare and the weather impacts on health and wellbeing, doctors can more proactively detect, prevent and treat those at risk leading to better patient outcomes and quality of life.

This could be calling someone in for a check-up. Or a patient could be encouraged to adopt remote monitoring technology such as a heart rate monitor and become more engaged in managing their LTCs such as coronary obstructive pulmonary disease or heart failure.

A small number of patients will also be provided with remote monitoring technologies such as blood pressure monitors which will be monitored by a team of nurses who will be able to see when a patient is at risk of deterioration earlier.

In the long term, it should change the way in which General Practice manage their population, enabling HCPs be more proactive and targeted in the care they deliver.