“Success was about involving clinicians in the redesign from the outset; focusing on areas of acknowledged problems; using low-cost existing technologies like SMS messaging; and making the system user-friendly for clinicians and patients. Telehealth needs to be disruptive enough to make care pathways change for the better and cheaper, but not so disruptive that clinicians and patients won’t use it.”
Paul Marriott, Project Lead, Innovative Telehealth Programme
What was the problem?
Telehealth technology has too often had a patchy record of adoption and success in the NHS. A programme funded by NHS England and the North East and North Cumbria (NENC) AHSN reviewed why this was not working well in their area. It has been successfully implemented and adapted to meet local needs, using a multimatrix model. The area has shown benefits in a number of clinical conditions and pathways, including patient-directed home management in two common pregnancy-related problems: mild pregnancy-induced hypertension (PIH) and gestational diabetes mellitus (GDM). Using this technology at scale is not common in the NHS.
What we did and why
Telehealth has been recognised as a potential means for reducing costs and extending the use of clinical resources available within the NHS. The Flo Telehealth system, using SMS/ text technology, was developed in the Stoke CCG area. It has now been used by over 23,000 patients. Evidence suggests that Flo increases levels of adherence, through educating and creating good habits in users.
Building on the successful telehealth pilot programme undertaken in South Tyneside from 2011, the NENC AHSN supported three linked projects to help embed the Flo Telehealth system in different pathways across the region. The projects developed pathways for various clinical areas: early examples of these included mild pregnancy-induced hypertension, gestational diabetes mellitus, and Type 1 diabetes in children and young people.
Flo is owned by the NHS, is cost effective to administer and is free for patients. The North East region was an early adopter of the Flo system. The NENC AHSN saw the opportunity to develop the use of telehealth across different pathways, using Flo, working with a variety of stakeholders.
Three projects using Flo supported by NENC AHSN are:
- Innovative telehealth programme across NHS Northern Senate
- Evaluation of telehealth monitoring in pregnancy using a multimatrix, multipartner model
- The participation and health improvement of children and young people (CYP) with Type 1 diabetes
Project funding allowed us to employ dedicated staff to help drive the initiatives forward. We established vital partnerships across the sector, and with North East universities and businesses. We developed patient pathways using the Flo system through engagement with key stakeholders; a steering group of children and young people collectively designed the text messaging system for Type 1 diabetes.
Staff received training where required, and we shared good practice with respect to pathway development. The programme of work in this area is a major factor in the North East region being the largest user of telehealth in the UK.
Which national priorities does this work address?
- Using digital technology in the NHS
- Providing community-based, patient-centred care
- The work of the projects contributed significantly to the growth of telehealth pathways currently running in the region, with hundreds operating and fast growth to scale.
- These telehealth pathways reduced the number of appointments a patient must attend, and medication can be titrated quickly, simply and safely.
- Cost savings become evident as pathways are developed and projects mature. Early indications suggest a saving of £300 per patient for the pregnancy-induced hypertension pathway and over £1000 per patient for the gestational diabetes mellitus pathway.
- The development of Flo in the treatment of Type 1 diabetes shows how the technology empowers children and young people to independently manage their condition and help others do the same.
- We recorded high levels of patient satisfaction.
- Evaluation of the pregnancy pathways programme in five hospitals across the North East has shown net savings of £100 per patient on the programme (as well as other health benefits with increased rates of breastfeeding).
“These services can be used in a multitude of ways, across the whole life spectrum, from hypertension to reducing the likelihood of cancer, maintaining healthy pregnancies through to end of life care and much, much more.”
Paul Marriott, Project Lead, Innovative Telehealth Programme
Tips for implementation
Get clinicians involved in the design from the outset – we got results by switching to a ‘troubleshoot-to-make-it-work’ approach, using a multi-matrix model of implementation. This approach meant getting clinicians engaged in the design at the start, getting the right equipment, and doing so at a unit cost that could compete or beat what was being spent on the existing care pathways. Without the involvement of clinicians driving change (generally, a senior GP partner or consultant), change is unlikely to happen.
Look for the ‘pinch points’ in care in the local health economy, as these vary by geography and health economy – ask local clinicians where these are, and if telehealth technologies could help them to provide care in those areas. If clinicians are involved in designing the telehealth intervention, they start to take ownership. Tailor the telehealth product to local clinicians’ needs for solutions.
You can have the best technically-specified, most modern kit in the world, but if clinicians don’t like its functionality or interface or think patients won’t use it, it’s no good. Understand the technical aptitude and resources of patients, as well as the local environment and tailor your product accordingly.
Make the product appropriate to broad pathways: think about care needs from pre-birth to end of life. Think about preventative gains – products to support quitting smoking will in time mean the health economy has less conditions such as lung cancer, COPD, and heart disease.
Unit cost is a major issue to making telehealth interventions cost-effective. This means knowing your unit cost per capita. To be viable, an intervention has to cost pence and pounds per thousand patients. Flo is effective because it blends inexpensive, simple SMS messaging technology with a wide variety of clinical pathways, such as reminders and confirmations of drug compliance for oncology.
Telehealth has to be disruptive enough to get clinicians to adopt it and patients to use it and take notice of it, but not so disruptive as to be off-putting. Successful implementation is about being wise, looking at right patient cohort, and always focusing on getting to a low unit cost. It is valid to have higher unit costs for higher cost patients, but to achieve reductions at scale, focus on avoiding the lower cost accruals.
Next steps and spread
- Measurement and evaluation of the pathways will help to build the evidence base.
- NENC AHSN will continue to work with other AHSNs to widen the reach and impact of Flo, to produce further cost savings.
Find out more
For more information, please see our main Adoption of Florence Telehealth page, which features films and other resources.
Visit the North East and North Cumbria AHSN website.
Contact for help and advice
Oliver James, Medical Director, NENC AHSN
Kirstie Taylor, Communications Director, NENC AHSN
Programme duration: 2011 – present