Florence: telehealth for long-term conditions

In the late 2000s, Phil O’Connell, a chartered IT professional with a background in telecoms and financial services IT systems, took an interest in the early NHS telehealth pilots.

Phil’s take was that NHS commissioners were being sold a pup – complex and costly IT solutions, often without much thought for how they would actually be used, which were unlikely to deliver substantial benefits. The emerging evidence was that a number of the original pilots were having few positive impacts, which contributed to loss of confidence in telehealth across the NHS.

The development of Florence started with a speculative email from Phil to a sympathetic programme director in Stoke Primary Care Trust. The message was that Phil could help NHS services use existing technology to support patients with long-term conditions, without the need for investment in new systems. The PCT provided a small amount of funding for Phil to develop the application and connected him with a local GP, Dr Ruth Chambers, to provide clinical input on design of the service.

A decade or so later, the result is a social enterprise, Simple Shared Healthcare, and an uncomplicated mobile phone application, Florence, which allows clinicians to communicate securely with patients, prompts patients regarding monitoring and treatment of their conditions, provides automatic advice based on disease management protocols, and gets in touch quickly if patients’ conditions deteriorate. Clinicians log on to Florence to get a simple overview of their cohort of patients and individuals’ conditions. 

The team have developed a number of standard protocols, for example medication reminders or smoking cessation messages. For patients with hypertension, the application provides reminders to take blood pressure readings at home using a portable monitor, avoiding the need to come into a surgery and ensuring more accurate readings. It provides automatic responses based on the data, telling patients if their blood pressure is fine, or telling them to contact the surgery if there is a deterioration in their condition. For chronic obstructive pulmonary disease (COPD), it prompts patients to check their sputum, asks about breathlessness, prompts patients to provide a temperature reading, directs patients to take rescue medication where needed, or alerts patients and clinicians if they need medical support. 

According to interviewees, however, Florence is an enabler rather than a solution for clinicians and their patients. Its greatest strength is offering a simple, adaptable framework for clinicians to work more effectively with patients and for patients to take a greater role in managing their conditions, without the need for costly investments in bespoke services. In one case, clinicians used Florence to help an individual with Asperger’s syndrome who struggled to sleep at night because of anxiety that he may have forgotten to lock the doors. Florence asks him to confirm that he has locked the doors every evening and reminds him that all’s well whenever he wakes up. 

This means that the benefits Florence can deliver are wide ranging, depending on how clinicians use the application. It has allowed Dr Parijat De, an endocrinologist at Sandwell and West Birmingham Hospitals NHS Trust, to substantially improve glucose monitoring and adherence to medication among his adolescent patients. This has led to more effective use of resources, for example, reducing the amount of time spent giving routine advice and the number of unnecessary appointments for patients whose conditions are stable, leaving more time to focus on those who are struggling to manage their conditions. Half an hour each Friday afternoon is enough for Parijat to review his list and identify where to focus his attention. 

Meanwhile, Florence can contribute to a dramatic improvement in quality of life for patients with long-term conditions. Simple prompts make it much easier to adhere to medication plans and keep things under control. Self-monitoring at home can remove the need for seemingly endless trips to surgery for testing or routine check-ups. For many patients, the greatest impact is on their self-confidence. Florence provides regular reassurance to patients that things are OK and they can get on with their lives, along with simple mechanisms for seeking help if things get worse. Over time, patients develop greater skill, understanding and confidence that they can manage their conditions. 

Florence is a low-cost, low-risk innovation with a strong track record. Providers simply need to purchase an initial bundle of text messages rather than making costly investments. It fits within and can be adapted for existing work processes rather than requiring substantial redesign. It doesn’t require staff to develop new skills or very different ways of working. Its effectiveness has been publicised by the National Institute of Health and Care Excellence (NICE), and the BMJ and a dozen or so other peer-reviewed journals.

Even with these enablers, the process of spread appears to have been difficult and, until the establishment of AHSNs, reliant on good fortune more than established systems. The initial development of the application depended on forward-thinking commissioners, connecting a talented innovator with clinicians, and small amounts of funding for commissioning staff to put ‘boots on the ground’, promoting the application to GPs, community nursing teams and hospital-based clinics. A common reaction was that people had more than enough on their plate with the day job.  

Respected doctors played a central role in persuading or cajoling colleagues into taking an interest in the application and exploring its possibilities, a role that could not be delivered by non-clinicians without established local networks. Nevertheless, the impression is of painstaking, incremental effort by these leaders to spread the innovation from one department in a provider to another, and then to neighbouring providers. In some cases, providers rejected the application because of the impact on their Payment by Results revenues, even though they could see the benefits. 

When the West Midlands AHSN decided to support Florence in 2014, it was the first time that Phil and his team had been able to access any form of regional infrastructure to enable adoption and spread. From working primarily with a single commissioner they were able to market Florence to all 22 CCGs in the West Midlands and had a route into a much larger number of providers. 

The AHSN supported the development of free CCG intelligence packs bringing together the evidence base for the programme, new off-the-shelf applications so that providers could start using Florence for people with asthma, diabetes or COPD straight away, and toolkits to help providers make best use of the system. They also provided a lifeline of funding for doctors such as Parijat to continue promoting the service to peers alongside their day jobs. This has led to an acceleration in adoption of the application in comparison with working with a single local commissioner. Within the first nine months of the AHSN programme, an additional 1,000 patients were using the system. The East Midlands AHSN is also now supporting adoption of Florence in its region. 

Nevertheless, it is clear that, seven years in, the project team is still at an early stage in the adoption and spread of Florence within large numbers of primary care, community and hospital services. Interviewees highlighted the ongoing need for clinical champions to support the programme and persuade individual organisations to adopt the service. 

Phil O’Connell noted the differences between working with the NHS and presenting Florence to the leaders of hospital chains or integrated health systems in Australia and New Zealand, or the Veterans Health Administration (VHA) in the United States, where leaders decided immediately to deploy a version of Florence – ‘Annie’ – in dozens of hospitals in the VHA system, drawing on accumulated experience and established systems to support implementation. The AHSNs offered the closest alternative in the English NHS, with technical skills and a route in to multiple organisations, although the resources that could be brought to bear were far from comparable.