Evaluating a Long-Term Conditions Intervention in Heywood Middleton and Rochdale

What are we trying to do?

As part of the NHS England Test Bed Programme, Heywood, Middleton and Rochdale Clinical Commissioning Group (HMR CCG), is testing an innovative, multi-component intervention, designed to help identify and support patients at risk of hospital admissions due to specific long-term conditions such as heart failure, type 2 diabetes and Chronic Obstructive Pulmonary Disease (COPD).  NIHR CLAHRC Greater Manchester is working with HMR CCG and the partners providing the various elements of the intervention ( MSD and Verily), in order to evaluate its implementation and its effect on several health outcomes.

Why is it important?

The number of people living with long term health conditions has increased significantly. Consequently, there is great interest in the development of interventions that can improve care for such conditions and reduce cost whilst improving outcomes and patient experience. The HMR intervention consists of three MSD elements:

  • MSDi – a data management tool which supports practices in managing long term conditions in line with national guidelines. It is a “risk stratification” tool that analyses health data, enabling GP practices to identify patients at increased risk of long term health conditions. This element incorporates customised algorithms developed by Verily to facilitate the stratification process.
  • EVIDENCE into PRACTICE™ – a 12-month facilitated, clinical change management programme which aims to offer a structured approach to the management of people with long-term conditions and works with the NHS to ensure that people with diabetes and COPD receive optimal care through effective implementation of national and/or local policy and guidelines.
  •  Closercare – a telehealth service where referred patients with COPD or heart failure will be provided with digital devices to monitor their own vital health signs at home, enabling health professionals to monitor patients’ health readings remotely.

This is the first time that the combined effects of these components will be investigated. It is this combination that makes the intervention innovative. The rationale for the intervention is that this combination applied over at least a 12 month period in one CCG will deliver a greater positive impact on health service utilisation (especially hospital admissions) than each component would individually.

How will we do it?

Our evaluation will involve two areas of focus:

Process evaluation

This will explore the acceptability of the intervention to health care professionals and how their behaviour fits with that intended by the programme leaders. It will also aim to identify factors that impede or facilitate implementation. To do this the project will use:

  • Observations of training sessions and delivery of CloserCare.
  • Interviews with primary care and MSD staff, CCG Change Team members and other CCG representatives.

Service evaluation

This will use hospital emergency department data to investigate any difference in health service utilisation pre- and post-implementation within the HMR CCG footprint as well as in comparison with another GM CCG.

Who are we working with?

Heywood, Middleton and Rochdale (HMR) CCG

MSD (known as Merck in the USA and Canada)


More detailed information on the rationale and research methods can be found by registering to access the study protocols below:

Please fill out the form below to view the HMR Test Beds Qualitative Protocol

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Please fill out the form below to view the HMR Test Beds Quantitative Protocol

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More information

For more information please contact Dr Susan Howard (Programme Manager) or Professor Peter Bower (Academic Lead).