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Secure text messaging with school nursing teams

Children and young people are at high risk of suffering a broad range of health and social challenges including sexual health problems, drug and alcohol problems, stress, anxiety, bullying and abuse, with a doubling in numbers of children self-harming or with depression in the past 10 years. At the same time, they are less likely than others to seek help from health and care services when needed, often because of lack of awareness of services, concerns about trust and confidentiality, or shame or embarrassment about their conditions.

In 2012, a group of school nurses in Leicestershire Partnership NHS Trust approached Jimmy Endicott, a manager in the trust’s communications team, for help to improve access to their services. All of the children and young people in their schools had mobile phones, which they used to manage almost every aspect of their lives. But when it came to the NHS, the only available option was to schedule a face-to-face meeting. They wanted to allow children to access help quickly and easily on their phones, but they needed to do this safely, ensuring that all calls were answered, taking swift action for children with severe challenges, keeping an audit trail and protecting confidentiality. 

Jimmy put a business case to the trust’s senior management team and secured agreement to work with the school nurses as a full-time project lead, as well as initial funding for the project. The director of the trust’s families, young people and children’s services chaired a project board to oversee the work. Over 2013, Jimmy worked with the school nursing team and a software developer to design a simple text messaging service for the children.

The result, ‘ChatHealth’, is a web-based application that supports safe and secure messaging between health care staff and service users. Children use a single hotline number or smartphone app to send messages. Staff log onto a secure online portal to view, forward, share or respond to messages. The system sends automatic responses to confirm that messages have been received, signposts alternative help out of hours, notifies staff when action is needed, keeps a track of messages that have been answered or remain unanswered and retains a record of conversations. It provides a mechanism for staff to manage their availability and their caseload and to share cases within teams. 

From 2014 to 2015, Jimmy piloted ChatHealth at the trust’s school nursing services, which cover 65,000 children and young people in Leicestershire and Rutland. It was implemented easily and delivered immediate benefits. In particular, school nurses started to receive around 100 additional requests for support each month. This included a substantial increase in first-time users and contacts from adolescent boys, who were previously less likely to access face-to-face school nursing services than girls. ChatHealth also provided a simple mechanism for children to contact school nurses during school holidays. Children explained that they were much more likely to send text messages than to ask for face-to-face meetings for advice on sensitive issues such as anxiety, relationships or sexual health problems.

Having successfully established ChatHealth across the trust’s services, Jimmy and his team secured funding from NHS England and the East Midlands Academic Health Science Network in 2015 so that they could establish ChatHealth across the country. This meant that they could continue to maintain a small team to market and implement the service. It also meant that they could access advice from the AHSN on issues such as intellectual property, marketing and commercial development of the service. 

Over the past two years, the team has supported adoption of ChatHealth within community nursing teams in 27 trusts across the country serving more than one million children and young people. They have achieved this through showcasing ChatHealth at testbed events and conferences, actively approaching large numbers of community service providers to persuade them of the benefits, providing hands-on support for implementation and attractive pricing. Organisations pay a licence fee to cover the costs of maintaining the service, but the trust does not seek to generate a profit. 

School nurses have explained that introducing ChatHealth has led to other beneficial changes in how they deliver their services. In the past, individual school nurses responded to small numbers of ad hoc queries from children while managing their face-to-face appointments. With ChatHealth, the nurses typically take turns in responding to the team’s messages, making it easier to respond quickly and making good use of staff time. The teams can manage greater numbers of inquiries with existing resources, while making it easier to offer timely face-to-face discussions for those who would most benefit. 

Some teams are now using ChatHealth as a route for helping children access other services and as a mechanism for linking together health, social care, police and others with an important role in protecting children. Others are using ChatHealth to share information with children on sexual and mental health. Meanwhile, the ChatHealth team is extending the service so that it can be used by health visitors, mental health teams and social services. 

One particularly striking feature of the project is the relative speed of progress from identifying the problem through to developing a new project and implementing it across multiple sites. It is possible to point to a number of unusual features of the project which might explain this: the chief executive and senior management of the trust had an interest in and prior experience of supporting innovation; staff at the trust were able to access someone, in Jimmy,  with specific commercial and project management skills for support; staff were able to access quickly the small amounts of funding needed to put in place a dedicated project team, rather than attempting to set up the project in their lunch breaks; NHS England and the AHSN stepped in quickly to support wider implementation, without the delays encountered in other projects.

Jimmy suggests that the initiation of the project by frontline staff and the development of ChatHealth within an NHS provider had advantages. Staff worked with external parties to develop a simple, low-cost system that fits seamlessly with existing services to meet a defined need. It is possible that NHS organisations find it easier than private firms to access senior decision-makers in other NHS organisations and to convince them of the benefits of new services. Conversely, NHS organisations were less well placed than private firms to market new services actively and to scale up to support implementation.  

Nevertheless, Jimmy emphasises the time and effort needed to support widespread adoption, even for relatively simple, proven services that fit smoothly with existing systems: ‘We aren’t able to have a single conversation with school nurses across the country about adopting an effective model. Instead we have to knock on doors one at a time. We spend a lot of time out on the road, meeting people, convincing them of the benefits of the system and then training them to use it.’