“Flo resembles a friendly, good-natured and trusted member of the family. I feel more able to cope and more confident about the future. Most importantly, it helps me cope with my situation.”
Jeff, Flo service user
What was the problem?

Telehealth technology has too often had a patchy record of adoption and success in the NHS, and using this technology at scale is not common in the NHS. Technology-enabled care services (TECS) of this kind can transform the way people control their health and reduce health / care usage. One example is Florence Simple Telehealth (Flo), an interactive texting service, free to patients and used across healthcare settings.

Flo actively supports the model of patient self-care management and compliance, while also delivering productivity gains for services, enabling larger caseloads to be managed within existing resources. Flo is owned by the NHS, and was created in Stoke-on-Trent CCG. At around eight pence per text, Flo is cost-effective to administer – and free for patients.

What we did and why

During 2014/15, the West Midlands Academic Health Science Network (WMAHSN) rolled out Flo to 2,489 patients with long-term conditions.

The UK population is increasingly diverse. Language, age and other factors mean methods of communication between clinician and patient are changing. Telehealth, telecare, telemedicine, telecoaching and self-care apps transform the way people engage in and control their own healthcare, so reducing valuable clinician time to take basic readings.

WMAHSN is investing in TECS for long term conditions (LTCs) to deliver patient convenience, understanding, experience, plus clinical and cost benefits. Flo is a texting service, free to patients, used across settings that is popular, easy to use, and designed by professionals to support and advise patients to manage their own health conditions. Flo combines the expertise of the patient’s healthcare team and the convenience of their own mobile phone, giving prompts and advice. If the patient needs more assistance, Flo helps monitor vital signs such as BP, pulse, and oxygen levels.

In 2015/16, the service was promoted to the whole West Midlands via all 22 CCGs and some acute and community trusts, alongside other forms of TECS:

  • CCG intelligence packs
  • Staying Independent online checklist
  • Apps (COPD, asthma and type 2 diabetes)
  • Skype and social media online toolkits (with some direct expert support)
  • general awareness of Flo Telehealth with some direct support and resources focused in North Staffordshire, Stoke-on-Trent, Stafford and surrounds and Cannock Chase CCGs related to COPD and asthma.

There is a wealth of additional interest and further innovations, and a focused evaluation is underway that includes capture of patient outcomes and feedback. Additional TECS being promoted are free access to CCG intelligence packs, the Staying Independent online checklist, apps (COPD, asthma, type 2 diabetes, and back pain), Skype and social media online toolkits (with some direct expert support).

The service hosted events across the West Midlands region to raise awareness of the range of technology that can support common long term conditions, including COPD, asthma and diabetes, and redress adverse lifestyle habits, using social media, apps, Skype and telehealth. The events were aimed at general practice teams (practice managers, practice nurses and GPs), CCGs and acute and community trust staff. The events, covering creating TECS in the NHS and digital delivery in the workplace, were attended by more than 200 delegates from a wide range of health professionals, GPs, practice nurses, CCG managers and trust representatives.

Other organisations are keen to learn about broader work around TECS, and the programme provides a good opportunity to share, promote and relate learning (including Skype, child and adult asthma avatar apps, the TECS referral pathway and other WMAHSN projects including STarT Back, the Manage Your Health app and COPD primary care training), so the Flo programme has developed a wider TECS scope. The extensive networking undertaken created further interest, links and opportunities in the Flo exemplar project and related TECS.

Matched funds from Stoke-on-Trent CCG supported the evolution of the TECS Staying Independent Checklist, a resource to allow health and social care and other professionals, during assessment of an individual’s support needs, to identify what TECS are available and suitable for them.

Which national priorities does this work address?
  • Funding and Efficiency, Health and Wellbeing
  • Medicines optimisation and self-care
  • Spreading best practice
  • Using digital technology in the NHS
  • Providing community-based, patient-centred care.
  • Integrated care development continues across participating organisations, and is now developing with other interested organisations – such as interest in Flo protocols from community pharmacies to support the delivery of their New Medicines Service and Medication Use Reviews, to support patients, better medicines optimisation and improved patient experience, and avoided healthcare usage.
  • A vision of how TECS underpins integrated care has been published (Tackling Telehealth 2) which describes different definitions of integrated care and how Flo and other TECS fit in. This draft paper received broad acknowledgement from clinicians around the country and key TECS leads at NHS England. The paper covers the transformative role that TECS can play in creating integrated health and social care systems based around the patient.
  • Since CCGs and healthcare trusts took out WMAHSN related project licences between April 2014 and March 2015, 2,489 patients have signed up to Flo, with some CCGs and trusts initially piloting Flo on Stoke-on-Trent CCG’s overall Flo licence prior to their own project licence being funded.
  • Heart failure (HF), diabetes and community pharmacy Flo protocols are ready for use. The HF protocols are related to an integrated care project between acute and primary care to up-skill GPs in the titration of HF medication.
  • Flo protocols have also been developed with a mental health trust and are now being deployed for pre-vascular dementia, mood management and depression.
  • Pilot protocols being evolved or used are pre-bariatric surgery weight loss, multiple sclerosis, community and secondary care pharmacies – new medicine and medication review services, wound fluid discharge, enuresis and informal carers’ stress.
  • There is a wealth of additional interest and further innovations:
    1. Primary care interest in proactive / preventative monitoring of acute HF patients through monitoring of patient submitted data, blood pressure, weight etc.
    2. Wound fluid discharge monitoring in a community setting, alleviating time for clinician to attend patient home purely for this purpose.
    3. Acute pharmacy interest in stratifying patients through A&E attendance due to medication issues and using Flo to support the patients with their medicines regime for a period of time post discharge.
    4. Anxiety / stress management for carers to support their wellbeing, therefore reducing the chance of failure of care.
    5. A focused evaluation is under way. The capture of patient outcomes has been included in the evaluation, with standard feedback captured at point of patient sign up to Flo and at termination and determined points in the Flo protocols.
  • The team is also working with each participating organisation to capture and evaluate their patient case studies to build a body of qualitative evidence to share and use to promote further the benefits of Flo.
  • The Flo data will be used to review patient adherence to protocol / pathway and, dependent upon the LTC, determine any sustained patient outcomes, such as blood pressure, or improved inhaler use.

“The app has excellent content, is quick to download and ensures patients have their asthma management plans with them all the time, rather than at the back of a drawer. Inhaler technique is key to managing asthma and the avatar demonstrates this perfectly. This app could help prevent hospital admissions and deaths.”

Sarah, Lead Nurse for Respiratory Medicine (general practice)

“The importance of what we are trying to help teams deliver cannot be overstated. Demands on our services are continuing to increase. Utilising technology will not only enable us to shape services to suit the needs and preferences of individual patients; embracing it will also help us take on the challenges we face every day.”

Dr Ruth Chambers OBE, GP principal, Stoke-on-Trent, Chair, Stoke-on-Trent Clinical Commissioning Group, Honorary Professor, Keele and Staffordshire Universities and Clinical Lead for Long Term Conditions, WMAHSN

Tips for implementation

To take Flo Telehealth and TECS forward at scale and pace, we need to:

  • Establish and support leaders and champions of TECS throughout the commissioning cycle to communicate the benefits and drive change.
  • Enable patient and public involvement and engagement.
  • Use digital modes of delivery (such as Skype, telehealth, telecare, teleconsultations or telediagnostics) to drive person-centred, integrated care, rather than standalone solutions.
  • Focus digital delivery of care on areas in patient pathways where enhancing self-care has a substantial impact by improving patients’ clinical outcomes and/or reducing avoidable healthcare usage.
  • Anticipate consequence costs, such as increased frequency of clinician alerts.
  • Train health and social care professionals: enhance workforce competences and capabilities for the roll out of technology enabled care.
  • Match the mode of digital delivery of care to suit the patient population – selected mode or individualised for their needs and preferences.
  • Rigorously evaluate any implementation or trial of TECS and use this information to underpin any future business cases.
  • Use improvement tools to underpin commissioning and service improvement – leadership, transformational change and service redesign.
  • Work closely with all stakeholders to integrate technology in care to improve outcomes for all services, and redress ongoing issues in constructive ways before progress with roll out is stalled.
Next steps and spread
  • To drive person-centred care through the use of TECS (with Flo as an exemplar) to span patient pathways across different healthcare settings with general practice teams and other providers prioritising applications that best meet the needs of their population, at specific points on those pathways.
  • To drive regional spread / deployment of TECS for LTCs within organisations to disseminate the knowledge and learning achieved from previous deployment and successes to support the move towards a culture shift / perception of TECS for asthma, COPD, medication adherence and hypertension.
  • Development of LTCs shared management website for clinicians and patients / carers to support TECS widescale adoption ready for 2016/17 to support other LTCs beyond the project’s initial launch protocols.
Find out more
Contact for help and advice

Dr Ruth Chambers
E: ruth.chambers@stoke.nhs.uk
T: 0121 371 8061

Louise Rowan, Communications Project Manager
E: louise.rowan@wmahsn.org
0121 371 8056

Programme duration

April 2014 – April 2016.