Background

In December 2019, a new form of coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in Wuhan in China.¹ The SARS-CoV-2 virus causes an infectious disease, which is referred to as ‘COVID-19’.² In January 2020, the World Health Organization (WHO) declared the outbreak to be a ‘public health emergency of international concern’.³ COVID-19 has been responsible for millions of deaths and hospitalisations worldwide.⁴ The WHO has reported that, globally, there have been 761,071,826 confirmed cases and 6, 879,677 deaths (as of 22 March 2023).⁵ COVID-19 cases have continued to fluctuate since January 2020. For example, since January 2020, England alone has experienced three waves of the COVID-19 pandemic (wave 1: March to May 2020, wave 2: October 2020 to February 2021, wave 3: began in July 2021 but has been complex to track and is therefore currently difficult to estimate when the end date was).⁶

COVID-19 is characterised by some common symptoms including a fever, a continuous cough, tiredness and loss of taste and/or smell.² In wave 1, there was a lack of knowledge of COVID-19 and treatment options compared with later waves. During the COVID-19 pandemic, restrictions on travel, social interaction and access to public spaces, known as a ‘lockdown’, were introduced worldwide. For example, within the UK, individuals were asked to stay at home (with the exception of critical workers, e.g. health-care professionals, food retail workers) and to socially distance from others.⁷ To minimise spread of the disease and increase capacity of health-care services, many routine health-care appointments were cancelled across the NHS or delivered remotely,^8–11 and parts of the workforce were redeployed.

COVID-19 is an acute disease with differential effects on the population. Diagnosis of COVID-19 can have many health, mental health, economic and social impacts on individuals. While many individuals develop mild to moderate illness, for some the disease can be life-threatening.² COVID-19 has been responsible for thousands of deaths and hospitalisations in the UK.⁶ As at 2 March 2023, the UK had reported 209,396 COVID-19 deaths.⁵ In particular, some groups have been shown to have worse mortality and outcomes from COVID-19 – for example, older adults, those with significant medical comorbidities, males, those living in more deprived areas, black and Asian ethnic groups, and those working in certain occupations (such as taxi/bus/coach drivers, retail assistants, construction workers, social care workers and nurses).¹²

Patients with COVID-19 may present with ‘silent hypoxia’ (very low oxygen saturations, often without breathlessness).^13,14 Patients may not be aware that they have low blood oxygen saturations, which may lead to delays in patients being escalated and admitted to hospital, presenting with more serious advanced symptoms of the disease. This has resulted in some patients needing invasive treatments and/or being admitted to intensive care units (ICUs), with a higher likelihood of mortality.^15,16

To deliver better and more personalised care to people in their own homes, services which enable patients to self-manage their health and care at home (e.g. remote home monitoring) have been identified as a priority within the NHS @home programme¹⁷ and the NHS Long Term Plan.¹⁸ Prior to the pandemic, remote home monitoring models have been used to monitor and provide care for patients with chronic health conditions [e.g. heart failure, chronic obstructive pulmonary disease (COPD), diabetes, kidney disease, cancer].^19–21 However, the COVID-19 pandemic enhanced and accelerated the need for health-care services to use technology in care delivery.²²

To reduce pressure on hospitals and infection transmission, and to ensure that patients with COVID-19 receive appropriate care in the right place and are appropriately escalated as early as possible, COVID-19 remote home monitoring models using pulse oximetry were developed and implemented in many different countries during the pandemic,^23–32 and are now recommended by the WHO.³³ The type of remote monitoring varies, in relation to the frequency of monitoring, mode of monitoring and recording (analogue or technology enabled), referral criteria and the inclusion of pulse oximetry.^23–32

Within remote monitoring models, patients take readings at home and submit these to a health-care professional in another location for review.³⁴ Pulse oximeters are small devices that can be placed on a person’s finger and used to measure blood oxygen levels. Pulse oximeters were used as previous research indicates that oxygen saturation may predict outcomes such as mortality and admissions to ICUs.³⁵ Patients, or their carer, measure blood oxygen saturations with a pulse oximeter (together with other measurements, e.g. temperature) at home. They record these readings in one of two ways: (1) recording readings on a paper diary and providing readings via telephone (analogue), or (2) recording and submitting readings using digital technology such as smartphone applications (apps), automated telephone or text (technology enabled). Once patients have submitted readings, a health-care provider reviews these readings elsewhere, escalating care when necessary.^32,36

In England, during the first wave of the pandemic, COVID-19 remote home monitoring models (pre-hospital and early discharge models) using pulse oximeters were implemented in a number of areas.³⁶ During 2020, NHS England and NHS Improvement (NHSEI) purchased and distributed them to clinical commissioning groups (CCGs) throughout England. NHSEI purchased 706,000 oximeters across waves 1 and 2 (Zofja Zolna, NHS England, 2020 personal communication). These pulse oximeters were European Conformity (CE) marked, as recommended by Medicines and Healthcare products Regulatory Agency (MHRA) guidance,³⁷ and were available to local sites within three days through an ordering system set out in the standard operating procedure (SOP). In November 2020, NHSEI launched a national roll-out of COVID Oximetry @home (CO@h) services.³⁸ Patients were referred within the community to the CO@h service (e.g. via general practices (GPs), COVID-19-specific community clinics, called ‘hot hubs’, and emergency departments). In addition, in January 2021, NHSEI launched a national roll-out of ‘COVID virtual ward’ (CVW) models, whereby patients were referred on to services upon being discharged from hospital early.³⁹ CVW models aimed to reduce pressures on hospitals by enabling early discharge and continuation of recovery at home. The national model of COVID-19 remote home monitoring, advocated by NHSEI, was for self-monitoring and self-escalation (with reference to clinical judgement), based on their learning from wave 1.^38,39 Self-monitoring and self-escalation refer to patients (or carers, where appropriate) monitoring their own readings and escalating their own care as necessary, with an option for prompts or check-in calls to take readings on certain days. This differs from remote home monitoring models whereby patients (or carers) submit readings to providers who monitor these readings remotely. NHSEI supported the national roll-out and local implementation of COVID-19 remote home monitoring services, including providing financial support for primary care to establish and implement COVID-19 remote home monitoring services,⁴⁰ resourcing NHS Digital to supply data to COVID-19 remote home monitoring providers to identify people who may benefit from these services,⁴¹ and the commissioning and funding of Academic Health Science Network (AHSN) patient safety collaboratives. This study included both CO@h and CVW models. Collectively, throughout this report, we refer to these services as remote home monitoring for COVID-19 patients (Figure 1).

FIGURE 1

A summary of remote home monitoring for COVID-19 services.

In addition, NHS user experience (NHSX) supported the implementation of COVID-19 remote home monitoring services through facilitation of the use of technology-enabled platforms. In the initial stages of roll-out (during wave 1), NHSX helped to pilot sites to use technology-enabled platforms as part of their CO@h and CVW services by signposting services to technology companies (however, it was up to local sites to decide whether the technology offered by these companies met their needs). In wave 2, NHSX funded and supported the implementation and evaluation of technology-enabled solutions for COVID-19 remote home monitoring services.

Despite previous research on the use of remote home monitoring models for other chronic health conditions,^19–21 there is a lack of studies exploring models of care developed to implement remote home monitoring across different health-care contexts during the COVID-19 pandemic. It is important to explore the implementation of remote home monitoring models within the context of a pandemic as it is likely that this context differs in relation to health-care pressures, patient needs and uncertainties. There is also a lack of studies evaluating the effectiveness and implementation of remote home monitoring models for patients with COVID-19, including in-depth analyses of patients’ and staff’s experiences of receiving and delivering care. This mixed-methods evaluation of remote home monitoring models in England aimed to address this gap by exploring the impact of the implementation of COVID-19 remote home monitoring models [on length of stay (LOS) in hospital, re-admission and health outcomes], the costs of implementing these models, the experiences of patients with remote home monitoring, staff involvement and experiences of delivering care and the processes used to implement these models at national and local levels. The study had a particular focus on inclusivity of these services and potential impact on inequalities.

Study aims

Research questions

Structure of this report

• Chapter 1 (context) outlines the rationale for this evaluation
• Chapter 2 (methods) presents the design and methods used (phases 1 and 2). Detailed methods are presented within each findings chapter.
• Chapter 3–11 (findings) outline the findings.
  • Chapter 3 – phase 1
  • Chapter 4 – implementation study (workstream 3 and 4).
  • Chapters 5 and 6 – effectiveness study (workstream 1).
  • Chapter 7 – cost analysis (workstream 2).
  • Chapters 8 to 11– patient and staff experience findings (workstreams 3 and 4).
• Chapter 12 (discussion and conclusion) – key findings, strengths and limitations, implications/lessons learned and future research.

Other related evaluations

Two other evaluations of remote home monitoring models for COVID-19 were commissioned alongside this evaluation, conducted by: (1) Institute of Global Health Innovation, National Institute for Health and Care Research (NIHR) Patient Safety Translational Research Centre, Imperial College London and, (2) the Improvement Analytics Unit (IAU; a partnership between the Health Foundation and NHSEI). Both evaluations investigated the impact of the CO@h service on mortality and hospital service use.^42–45 Imperial College London also examined inequalities in the enrolment of eligible patients on to the CO@h service and conducted quantitative evaluations of differences between technology-enabled and analogue pathways.⁴⁶

The Birmingham, RAND and Cambridge Evaluation Centre (BRACE) and Rapid Service Evaluation Team (RSET) also investigated the use of pulse oximetry in care homes across England and completed a mixed-methods rapid evaluation using an online national survey sent to all care homes in England and qualitative interviews with staff from six care homes acting as case study sites (see Sidhu et al.⁴⁷).

Working with stakeholders

Throughout the evaluation, the team worked with a range of stakeholders at national and local levels (phase 1: community of practice, phase 2: NHSEI, NHS Digital, NHSX, community of practice, national learning network and Clinical advisory group).