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Supporting carers through loneliness and isolation with Flo

posted 1 Jun 2017, 01:58 by Hollie O'Connell

Madeline Martin 
Carer Coordinator - Edinburgh Carer Support Team 

05 June 2017 

Helping carers to care through loneliness 

It is estimated that there are seven million people in the UK who are caring for older, sick or disabled loved ones.  In Edinburgh, the Scottish Health Survey (2013) estimated there were 65,084 unpaid carers.  From this number, 36% of carers provide 20 or more hours of unpaid care per week and 21% provide over 50 hours or more of unpaid care. 

Caring for a family member or friend can be a positive life experience but this can also be a cause of loneliness and isolation which can affect the carers own health and wellbeing.

Chief Executive of Carers UK, Heléna Herklots said in the report ‘Caring Alone’

Caring for a loved one can be hugely rewarding but without support to have a life outside of caring, it can also be incredibly lonely.  Pressures on finances, a lack of support to allow carers to have a break and a lack of understanding from friends and colleagues, mean many carers feel that their world is shrinking. "

In 2015 Carers UK published a report called 'Alone and Caring' to highlight the issues carers struggle with due to their feelings of loneliness and isolation.

The key findings in the report were as follows:
  • 8 out of 10 carers (83%) have felt lonely or isolated due to their caring role 
  • 57% have lost touch with family and friends as a result of their caring role
  • Over a third (36%) feel uncomfortable talking to friends about caring, adding to feelings of loneliness and social isolation 
  • 45% couldn’t afford to take part in social activities 
  • 49% have experienced difficulties in their relationship with their partner because of their caring role 
  • 55% of carers felt that they were unable to get out of the house much due to their caring responsibilities

The Edinburgh Carer Support Team, based within the Department of Health and Social Care offers one to one support to carers who either self refer or are referred internally by a health or social care professional.  Our contact with carers varies depending on their situation and personal requirements.  Support workers can be involved for a short period of time or in more complex cases, they support carers over a period of months.  In both cases, staff were always aware that when their involvement with a carer comes to an end, the caring role often continues and can change, at times, becoming more difficult.  When this happens we were aware there was a ‘gap’ as carers don’t always remember they can still contact the team, or any partner agency for further support and this could lead to feelings of loneliness or isolation.

In 2015, through NHS Lothian, we were given the opportunity to use a Telehealth App called Florence, as a way to ‘keep in-touch’ with carers who had used our service but were no longer actively receiving support from a worker and we felt this could help us bridge the ‘gap’. 

How does Florence work? 
Carers give consent and are enrolled by their carer support worker to Florence which is essentially a text message based system. The carer then receives a series of texts over nine months which offers reminders, motivational prompts and relevant carer support information on a variety of issues. The texts to the carer are generally free and the carer can opt to stop receiving these texts at any time.

When asked what they thought of ‘Florence’ a carer said, 

I love getting all these Flo messages. I think it’s a great idea. It makes me realise I’m not the only one with problems. It gives me a little prompt and makes me think of my Carer Support Worker when I receive a text from Flo.  

One of the texts prompted this carer to look into a Mindfulness course which was being run by a local carers organisation.

Another carer commented,

Flo lets me know what is available and what is coming up. It prompted me to check in with my local carers centre and as a result I am hoping to get back to bingo with my sister. 

Liverpool Health Trainers and home blood pressure monitoring

posted 25 May 2017, 06:00 by Hollie O'Connell   [ updated 30 May 2017, 08:40 ]

Sharon Poll 
Liverpool CCG - GPN Lead 

30 May 2017  

Hypertension case studies 

Liverpool Health Trainers is managed by Person Shaped Support, they help to empower and enable referred patients to manage their health better through education and support.  They have been using Florence to help monitor blood pressure and have shared some of their case studies. 

Patient X was referred to their Health Trainer via their GP practice.  The patient had been experiencing strain from their overall health issues combined with a high blood pressure reading which may have been making the patient feel worse. 

The patient’s GP identified an opportunity for the patient to be introduced to Flo to facilitate the collection of short term home blood pressure readings.  The patient’s GP was keen to understand if there was any change in the patient’s blood pressure at home from that recorded at the surgery to inform a diagnosis or exclusion of hypertension, and to ensure the most appropriate treatment plan was arranged for the patient. 

The Health Trainer provided the patient with a hypertension diagnosis shared management plan, and explained to them how Flo would prompt them to send in their blood pressure and also offer advice dependent upon the patient’s reported readings as agreed with their GP.  These readings would then be reviewed at the surgery to inform on-going treatment. 

The patient left their appointment with their Health Trainer reassured and enrolled onto Flo, awaiting their first request for their blood pressure reading. 

Upon further review of the patient’s blood pressure readings, their average blood pressure was within the normal range compared to readings taken solely at the practice, and a diagnosis of hypertension was excluded by the GP. 

The Health Trainer commented that having the time to discuss Flo and how she can support the patient’s on-going treatment plan was useful.  The patient reported that on the day he had his blood pressure taken in surgery, his shirt had been tight and he was anxious which may have impacted on a false high reading.  Using Flo provided the patient with reassurance that their real time home blood pressure readings could be reviewed to provide data for an accurate diagnosis without the impact of external influences brought about by attending the surgery. 

The Health Trainer commented;

" Florence totally sorted this out as the patient was more relaxed and not rushed doing it at home. The patient now feels far more reassured. "

Patient X with uncontrolled hypertension was referred to their Health Trainer by their GP to use Flo.  The aim was to support the patient in improving compliance with their hypertensive medication and for education and motivation to adopt a healthier lifestyle in support of gaining better control of their blood pressure. 

On meeting the patient, the Health Trainer discussed Flo and how she can support the patient’s on-going treatment plan.  The patient was quickly enrolled onto an 8 week programme with Flo supported by a shared management plan and guidance on how to take home blood pressure readings. 

The Health Visitor offered to create a Personal Health Plan for the patient, however the patient was keen to follow Flo’s programme and to make the necessary lifestyle changes. 

Over the 8 weeks since being introduced to Flo, the patient’s blood pressure control has significantly improved 
  • Week 1 - average BP 163/122 
  • Week 8 - average BP 142/98 

The patient was thankful for Flo’s additional support and commented that Flo was " a real help to him and kept him on track " and explained to his Health Trainer how he could see the improvements in his blood pressure and the difference it was making for him. 

Importantly, the patient is now also more aware of the importance of taking his medication as prescribed and aims to continue to make further lifestyle improvements.

Patient X was referred to her Health Trainer by her practice nurse. The patient’s blood pressure was remaining high regardless of prescribed medication aimed to control it.  The nurse had identified using Flo as a tool to compliment the care already being given, helping to motivate and educate the patient to adopt a healthier lifestyle in support of gaining better blood pressure control. 

Flo was discussed with the patient and the Health Trainer explained what the patient could expect over the next week of home blood pressure monitoring.  A demonstration of how to use the blood pressure monitor was provided and a shared management plan was agreed with the patient. 

The Health Trainer explained the risks associated with high blood pressure and provided brief information regarding how lifestyle improvements can help to control and reduce high blood pressure. 

The patient visited her GP a few days later and through a discussion around her blood pressure realised she should have been taking three tablets rather than two.  The patient’s GP advised her to increase her medication to the prescribed dosage, and to continue to report her blood pressure to Flo for a further two weeks.  With the patients improved medication adherence, the GP could review the impact of the new dosage.

On review and after increasing her medication to the prescribed dose the patient’s average week reading was 151/98 mmHg.  The patient continued to take her blood pressure at home and send them to Flo for a further two weeks.

In the meantime the Health Trainer sent the patient’s blood pressure readings that had been reported to Flo to her GP.  Having reviewed the readings, the patient’s GP called her to ask that she return to the surgery to discuss her medication.

Based on the patient’s reported home blood pressure readings via Flo, the GP was able to intervene earlier upon identifying that the patient’s blood pressure medication needed to be increased; the GP subsequently requested that the patient continue to send Flo her home readings for a further week.

At the patient’s last review, the benefits of leading a healthy lifestyle were recapped, and information on the Health Trainer service was provided for any help or support to make lifestyle changes.  The patient’s average blood pressure at the end of the home monitoring via Flo had fallen to 118/84 mmHg and the GP was now confident that her antihypertensive medication had been titrated accurately.

Person Shaped Support takes pressure off GPs in Liverpool

posted 4 May 2017, 00:55 by Philip O'Connell   [ updated 5 May 2017, 04:37 by Hollie O'Connell ]

Lee Lewis 
Liverpool Digital Health Service Manager 

4 May 2017 

Assisting the diagnosis and management hypertensive patients outside of the GP surgery 

The Digital Health Service in Liverpool are currently managed by Person Shaped Support (PSS). The primary purpose of the service is to introduce people to technology, empower people to use Florence to self-care and take more of a leading role in managing their blood pressure. They also aim to educate members of the local community about issues surrounding blood pressure, predominantly in primary care settings.

What is Liverpool’s Digital Health Service? 
The approach we take is similar to the one we originally took as Health Trainers, in that individuals are referred to us from their GP surgery. However, the focus now is on blood pressure, rather than lifestyle as a whole as it was previously. People often respond differently when being given lifestyle advice than when they are being told they have high blood pressure. With blood pressure, most people know something about it, know some of the risks it entails, and they respond better to this. 

To support people with their knowledge of blood pressure we have developed our own service user booklet which provides key information around how to use Florence, and includes the patient’s management plan and some basic lifestyle advice.

How does Flo feature? 
When a patient is referred to us, we are able to set them up on Flo to monitor their blood pressure. We frequently use the AIM 01 protocol designed to prompt patients to take their blood pressure twice a day, as per NICE guidance, to collect sufficient readings for a GP to diagnose or exclude hypertension. We can offer this to patients without a referral from their GP. The readings we receive are shared with the surgery, and then the GP is able to decide if further action is required to treat the patient's blood pressure. They often refer the patient back to us so that we can enrol them on the AIM 02 protocol to measure their blood pressure over a longer period aiming to improve hypertension control. 

You would assume that most people are having their blood pressure checked, but this isn’t always the case. Many people only have their blood pressure taken during a health check or if the clinician needs to investigate something further, but generally most people who present at their surgery don’t have it taken. At the moment in Liverpool there is quite a long waiting list for ambulatory blood pressure monitoring, so the GP surgeries really like the idea of referring patients to us, as an alternative.


What benefits have you seen so far since Flo’s introduction?

With the help of Flo, we are able to provide information that will help GPs to diagnose hypertension, which saves them time, as well as reducing the anxious wait that a patient may have if they are on the waiting list for blood pressure monitoring. Additionally, we can use Flo to help clinician’s determine what medication and the dosage a patient requires to bring their blood pressure under control.

We have also found that a number of patients want to continue using Flo as it reduces their concerns about their blood pressure; they have increased knowledge and awareness of blood pressure and they therefore feel more in control of their own health.

What’s next for the Digital Health Service? 
We have been working hard to make sure that The Digital Health Service becomes more visible. We have been engaging occupational workplaces, such as the police force, to support staff and pick up on issues surrounding blood pressure. We now feel that due to PSS’s work within primary care settings over the last few years, we have built a lot of trust with the primary care services in the city. The GPs and clinicians know that we are capable; we can support patients, we are professional and everything we do is done in the correct manner. Liverpool is lucky; there are a lot of great clinicians here, and they have opened doors to engaging with both the communities and services in the city. They recognise that a medical approach is not the only option available, and that holistic approaches offer something just as valuable too. 

The key really is to talk to as many people as you can and promote what you do, be that at conferences, or just by attending meetings with different organisations. Flo is a great example to use for us, as we can engage patients with the benefits and how Flo has helped patients. We found that being able to talk about these real situations that relate to patients made a difference to how willing some GP practices were to be involved with us and engage with the service we can offer their patients. 

Going forward, we would like to develop the use of hubs across the city. These will create access routes into the service for primary care. The aim is to reach out to as many people as we can; be that working with other services to improve care, or just making ourselves more visible to the local communities. We want to help as many people as we possibly can, and Flo is tremendously important to this. 


We recently helped a young man reach a diagnosis of high blood pressure using Flo. The patient was suffering with ongoing headaches, however despite having quite a strong family history of high blood pressure, he hadn’t linked the two together. We enrolled him with Flo to monitor his blood pressure and discovered that it was quite high, especially given that he was only in his early 20’s. From that point, we were able to pass on the information to his GP, who referred him back to us to put him on to the AIM 02 protocol to continue to monitor his blood pressure. The patient has since been sent to a specialist hypertension clinic to help him further with his blood pressure.

This isn’t an uncommon example when it comes to younger patients; we find that a lot of younger people aren’t as engaged with their health, especially when its things like hypertension which are traditionally associated with older individuals. However, once we sat him down and gave the patient the necessary education about his situation, he took it up and started to follow the advice and guidance.

There are many scenarios like this where we, helping people to engage with their healthcare, and Flo is a really helpful tool for us. We don’t just engage people in primary care settings, but also work closely with community and occupational settings.


More recently we have just engaged with a patient who was a 50 year old male, who had suffered from a stroke within the past 18 months. The patient was found by the surgery using the EMIS Flo searches, which our service provides; these were developed for the surgery with the support of Informatics Merseyside and Liverpool CCG. The client had previously been diagnosed with hypertension in 2015 but his readings were still high, especially his diastolic, even with the patient being on medication.

The patient was put on AIM 01 for one week to monitor and get a more accurate measurement of his blood pressure at home. The patient was a bit apprehensive at first about coming in to see the Digital Health Advisor (DHA) as he was not 100% sure why he was there. The DHA explained the service, what Flo was and how it was being used to monitor the blood pressure of patients. After discussing this, the patient divulged that directly after his stroke he was regularly seeing his practice nurse, having a variety of checks including blood pressure, but after 6 months the visits ceased. He felt strongly these routine visits should have continued, particularly as his blood pressure was not being monitored by the practice, which really concerned him.

The DHA explained to the patient that by using Flo we were able to monitor his blood pressure at home without the need for him to physically come to see the nurse (unless needed), and his results/readings would be put on to his records for all clinicians to see. The DHA also gave lifestyle advice on how to help manage his blood pressure better. After using Flo for one week the patient improved his compliance with his medication; he had noticed that on days when he took his medication as he should, there was the desired effect on his blood pressure. Previously the patient hadn’t been taking his medication as instructed, but as he started to use Flo he could see that it was actually helping.

The patient’s initial blood pressure on AIM 01 was 127/91mmHg, and his blood pressure at the end of the week was 122/79mmHg; this was an average across the 7 days, taken twice a day. The client is now fully complying with taking his medication as instructed. The patient asked if he could continue to be further monitored, as he felt reassured that his blood pressure was constantly monitored and fed back to the surgery. We discussed this and put the patient on AIM 03; he is now sending in his blood pressure once a week for 13 weeks. Since using Flo the patient’s blood pressure has improved with once weekly readings showing 135/85mmHg, 133/85mmHg, 130/84mmHg, and 112/73mmHg respectively. The first three readings were all taken between 16:00 and 18:00, with the final reading being taken at 22:00.

Across the UK, inclusive Flo helps patients regain control of their diabetes

posted 11 Apr 2017, 04:25 by Hollie O'Connell   [ updated 5 May 2017, 03:26 by Philip O'Connell ]

For patients, not profit 

Hannah Mountford 
Assistant to Director of Services and Community 

25 April 2017

Friendly Flo helps patients regain control of their diabetes

Flo has been helping patients with diabetes to manage their condition for sometime now, and since being introduced to Flo, patients have since seen improvements in their health and clinicians report improved productivity and efficiency. It is useful to take an overview across all diabetic pathways that Flo supports to understand the differences that Flo has made to people’s lives, as well as what makes her so helpful to both patients and the clinicians.

Many of the patients that Flo now supports had been experiencing difficulties in managing their diabetes before becoming acquainted with her, or were at particularly high risk of further complications or exacerbation if their diabetes remained uncontrolled. Patients and clinicians reported experiencing a number of self management challenges: 

  • Adherence to blood glucose monitoring and self management advice
  • Titration of insulin
  • Understanding diabetes for newly diagnosed patients and how dietary and lifestyle changes can significantly impact on clinical outcomes
  • Compliance with the administration of prescribed medications, including insulin
  • Increased secondary care admissions due to complications caused by uncontrolled diabetes
  • Management of comorbidities associated with diabetes such as diabetic foot care

Compounding patient’s present challenges with managing their condition, the trajectory toward further complications when diabetes remains poorly controlled is inevitable . Poorly controlled diabetes increases the risk of amongst others cataracts, glaucoma, various foot complications, cardiac and kidney complications are also more likely. All of these complications can be avoided or have the date of onset delayed by maintaining stable blood glucose levels. The reduction in cost implications and clinical impacts are significant

Since meeting Flo, patients demonstrate that her relevant, real time advice, aligned to their shared healthcare management plans is helping them to become more engaged and regain a feeling of control over their diabetes and lives again, along with reducing their HbA1c significantly improving their future clinical outcomes. 

Flo has been helpful for younger patients with type 1 diabetes also. Younger patients have the additional challenge of accepting their often lifelong diagnosis at a young age which often leads to disengagement with self care resulting in uncontrolled blood glucose. This feeling of overwhelment is compounded by needing to engage with their condition to manage their diabetes with competing pressures, such as school and socialising. 

Many patients who use Flo report that they now feel more engaged and in control of their diabetes and are now adherent to their self management guidance resulting in more stable blood glucose levels. This improvement in blood glucose control supported a reduction in hospital attendances and demonstrated an overall improvement in patient's general health and wellbeing. 

“ Flo has helped to tighten the control I have on my diabetes and check my blood levels more regularly. As a result I’m more careful with lifestyle choices in the absence of exercise while I am continuing to recover, and I am thrilled that I have been able to stop injecting insulin. ” Brenda Greaves.

It isn’t just patients who are finding Flo useful; many of the health professionals who care for patients with diabetes are reporting the benefits of enlisting Flo as a member of their team. Feedback from clinicians demonstrates that Flo not only improves their patients health and well being, but is time and cost effective. Furthermore, they are reassured knowing that the safety of their patients is improved when away from face to face care.

“ We’re getting less calls from women who just require reassurance, they're getting that from Florence. The calls that come through are the ones that really need the support. So we’re able to counsel women who need some more advice, or maybe some treatment, and that’s reducing call times. It’s also reduced the cost in prescriptions, less women are needing prescription because they're managing their diabetes better. ” Victoria Bowman, midwife.

Key to patients engagement with Flo is how simple and convenient she is to use. Patients only need a simple mobile phone and to be able to open and send texts messages. What’s more, provided patients take any equipment they need to take their measurements with them, they can respond to Flo from wherever they are that day without the need for a mobile data contract or WiFi. This is convenient as it means patients are not tied to staying at home to monitor their diabetes and therefore more likely to take a more active role. In addition to convenience and ease of use, Flo reassures patients if there are any concerns with the readings reported with clear advice and guidance from their agreed health care management plan.

Flo has a unique friendly, human-like persona. Patients respond well to this discreet interaction and come to see her as a friend on hand to help them self care. Flo empowers patients by giving them the confidence to take responsibility for their own health and wellbeing.

 Flo has made such a big difference to my life. I would definitely recommend it to everyone. ” Naomi

" I recommend it be rolled out absolutely everywhere. Josh

Boosting awareness of Telehealth in Lanarkshire - Fraser's story

posted 17 Feb 2017, 04:18 by Philip O'Connell   [ updated 25 Apr 2017, 07:58 by Hollie O'Connell ]

Euan Duguid 
Communications Support for Telehealth 

21 February 2017

Boosting awareness of Telehealth in Lanarkshire - Fraser's story 

We use technology like mobiles and tablets at work at rest and at play.  For some, however, it may take a quantum leap of the imagination to picture the text message at the heart of health care.  For others, it may strike (unfounded) fear into their hearts – and suggest their friendly local health professional is being replaced by automation.  The fact is, Telehealth is now a major tranche of health and social care delivery – augmenting traditional supports, ensuring patient safety and supporting people to lead independent lives.

My aim, from a communication perspective, was to raise awareness, providing a clear and reassuring public/staff message of what Telehealth is, how it works and highlight its multiple benefits. And given we’re dealing with communication technology we also wanted to add a healthy dash of innovation and interactivity to the process . . . 

So how did we go about this? 

Based on real life case studies, clinical advice from my colleague Morag Hearty, NHS Lanarkshire’s Telehealth Lead, along with her expert team, a script was developed for an animation that sought to meet all of above aims.  The resulting production told the story of Fraser, who’s supported by Telehealth/Florence.

No spoiler alerts . . . . please do watch the short animation to find out more. 
(NOTE: also available here https://vimeo.com/198187123?lite=1)

Communication these days isn’t just about sending out messages. It’s often about involving our audiences and social media allows that to happen.  Fraser struck a chord with many people (his animation has been taken to events and conferences locally, nationally and even overseas). But, he’s a lively character - and we really wanted to draw on his joie de vivre and bring him to life.

So the second phase of Fraser’s journey has just begun!

We’ve just launched (in February) our second short animation – and, as the story goes (spoiler alert!) Fraser is so active you can find him out and about across Lanarkshire and, indeed, beyond.  So the challenge we’ve issued to staff groups and the wider public is to #FindFraser

Our Telehealth team have been busy distributing posters of Fraser all over. From voluntary sector cafes, leisure centres to GP waiting rooms.  When people see the poster we’re encouraging them take a close up photograph of him, post it to social media using the hashtag #FoundFraser.  In turn, they receive a reply from Fraser, signposting to the original animation and more information about Telehealth.

Has Fraser been successful? 

Well, the original animation has received positive feedback and has now been shown UK-wide by a variety of partners and agencies, including Simple Telehealth Community, NHS 24 and Scottish Centre of Telehealth and Telecare.  Further feedback from clinical leads shows that the animation has resonated with and is even being used by health professionals overseas.

Local media have publicised the animation and partners in Lanarkshire’s health and social care landscape, including local authority, third sector and carer representatives are sharing Fraser’s story through their own extensive networks. Many hands make light work . . . .

So, the original aim, to raise awareness of Telehealth, is on track in terms of reach - with additional feedback suggesting audiences ‘get it’ after watching the original, easy-to-follow animation.

In practical terms, Fraser’s story is supporting an upward trajectory of 2000 Telehealth users in Lanarkshire and there’s early evidence showing that he’s boosting uptake of Telehealth elsewhere in Scotland.

Finally, the interactive #FindFraser campaign will now allow us to accurately measure how many people are engaging with Fraser, through social media analytics.

Exciting times.

See Fraser featured in 'The Pulse' for NHS Lanarkshire April/March 2017.

Astonished clinician's poem captures feelings about her friend, Flo

posted 10 Feb 2017, 10:39 by Philip O'Connell   [ updated 12 Feb 2017, 06:32 ]

   Lisa Taylor

   10 February 2017

Clinicians often tell us that after being disappointed with technology initiatives, at first they take a cautious approach with Flo, but Flo soon captures their hearts and minds. 

Seeing is believing and when the evidence of her impact on patient engagement is seen over and over again, delivering  positive changes in motivation and ability to self-care, apprehension gives way to confidence. 

We are always delighted to hear these real world stories backed by genuine evidence from clinical practice and they are told with such passion.   We really can't help but be emotionally moved by them. 

However Jill Hyden, ILCT Team Leader at Staffordshire and Stoke-on-Trent Partnership Trust went just one step further, documenting what it meant to go on a Flo journey.  So with Jill's kind permission, reproduced across the page is her team’s story about  ‘our friend Flo’. 


Jill’s team in Great Wyrley implemented Flo as part of their diabetic pathway and saw their patients renew their confidence in their diabetes management whilst releasing an average of 90mins of nursing time each day for one particular patient. 


The NHS is a magnificent beast
It has a duty to care, at the very least
Demand is high, finances low
We have to look, where new seeds we can sew

Now we’re a team who embrace new ideas
Despite all our IT fears
To provide great care yet promote independence
Any good ideas we’ll take in abundance 

A new system called Flo had been introduced
So nursing time could be reduced
Give patients confidence to manage their condition
Without it being a nursing omission

We had a patient who just needed support
To administer her insulin, she’d already been taught
2 visits a day was what was required
Until this new system we acquired

A bit of persuasion, decision is made
Our nursing care will get an upgrade
Patient’s permission granted, to share information
No turning back now, we're in for the duration

Unsure, but we’d give it a go
But who was this lady called Flo
Technology – we were a bit apprehensive
At this alternative way of care to give

Late Friday afternoon, friendly voice in my ear
Instructions given were really clear
Don’t give up we're nearly there
Mission accomplished, I was astonished to be fair!

A simple text was all it took
Our visits reduced, we were off the hook
Blood sugars monitored, insulin taken
A new era of confidence was awaken

Independence gained, a new lease of life
No longer tethered together, like husband and wife
Freedom for the patient, time gained for the team
Worked like magic, just like a dream

Providing quality care which is cost effective
Is the type of care we all aspire to give
Despite the challenges we had to try
Sink, swim, or we might even fly

So if you’re thinking about trying Flo
Go ahead and give it a go
Mighty oak trees from little acorns grow
So spread the news about our friend Flo

 Jill Hyden

Nuffield Trust: "Flo has been formally evaluated, with positive results"

posted 24 Nov 2016, 06:50 by Philip O'Connell   [ updated 25 Nov 2016, 01:07 ]

Phil O'Connell 

24 November 2016 

A few days ago, the Nuffield Trust published a Research Report; "The digital patient: transforming primary care? ".  The report provides welcome and thoroughly researched analysis on the use of digital services in healthcare in the UK.

"For this report, we conducted a literature review, interviewed 21 experts – including representatives from technology companies, policy, academia, patient organisations and health care providers – and held a workshop to test and refine four future scenarios. We also undertook four case studies comprising
 of desk research and one or more interviews with key people at the featured organisations."

"A professional monitoring system in action: Florence (Flo) – a case study"

We were delighted to find that Flo has been highlighted as one of the four case studies.  Drawing from multiple sources including the national AIM programme and Bay Medical Group's CQC "Outstanding" citing for use of Flo, the case study discusses the merits and some of the earlier issues found and how they were addressed by those teams.  In particular it's about getting the protocol right for the intended purpose and target cohort, and in the case of Bay Medical Group, they modified the protocol to fit their shared clinical management plan, whereas the earlier national AIM study (Cottrell et al) offered less flexibility and ability to change what in hindsight were quite verbose protocols for use over a 2-3 month cycle.   The learning from this earlier work now forms part of the established knowledge-base of 1,000+ applications of Flo, available to members of our Community of Practice. 

"To improve engagement, there are a number of things professionals can do: 

  • where patients are asked to send readings, send reminders at the time the readings are due and limit all other communication 

  • clearly communicate the commitment required from patients at the start of the intervention 
  • carefully select patients with the capacity for (and ideally interest in) self-management – particularly as monitoring can be costly (see Slomski, 2016). See Chapter 4 for broader considerations about engaging patients.

"The evidence base behind Flo"

"Flo has been formally evaluated, with positive results. It is considered to be easy to use, convenient and reassuring for people across a wide age range (Cottrell and others, 2012; Cund and others, 2015). Both patients and professionals have found that Flo can help patients to develop a better understanding of their condition, medication and lifestyle and improve condition management (Cottrell and others, 2015a; Cund and others, 2015)."

"A dystopian distraction"

The report goes on to echo our message on the the dangers posed by sales driven technology companies and the need for robust evidence and how these technologies should be evaluated, recognising that not many would actually reach the standards achieved with Simple Telehealth and Flo.  To become approved, the technology would have to go through a four stage process, culminating in "Independent impact evaluation by an NHS body".

"Strong marketing campaigns by the private sector may mean that the most fashionable or popular consumer technologies are used at scale, rather than those that have been proven to be effective."

Lead author Sophie Castle-Clarke, Fellow in Health Policy at the Nuffield Trust, said:

Technologies that patients can use offer some of the brightest hopes on the NHS horizon. Digital tools that help people stay healthy and manage their conditions at home will be critical to the future of the health service. The good news is that this is increasingly becoming a reality in the NHS."

But this technology could be a double edged sword, and there’s still a lot we don’t know. Without regulation and a careful look at the evidence – not all of which is compelling – these digital tools could compromise the quality of care and disrupt the way care is provided.

At simple.uk.net, we are pleased that this timely Research Report highlights the huge potential for the NHS if genuine, evidence based technologies such as Florence are encouraged and adopted.

Epilepsy, Chronic Myeloid Leukaemia, Paediatric Diabetes, Parkinson's Disease and Gestational Diabetes at Newcastle Upon Tyne Hospitals

posted 13 Oct 2016, 06:14 by Philip O'Connell

Newcastle Upon Tyne Hospitals 
NHS Foundation Trust 

Anita Brockbank 
Una Brechany 
Karen Hamlen 
Kerry Camara 
Deirdre Frost 

17 October 2016 

Newcastle Upon Tyne Patient Stories and Experiences with Flo 


Florence has been successfully used by Newcastle Hospitals to motivate patients with epilepsy be more compliant with their medication; revealing impact amongst both with younger and older patients. 

Patients and their families report that they are now reassured that medication has been taken regularly and on time and feel supported in this, with this improved medication compliance resulting in improved symptom control

The team have also noticed that where the patient stopped Flo’s use after a short period, medication compliance was demonstrated to subsequently diminish,. The team feel that this clearly advocates a longer-term use for Flo with this cohort to help sustain the behaviour change particularly for patient with additional mental health conditions. 

Case studies 
Patient 1) One younger patient receiving daily medication reminders via Flo is an 18 year old whose mother encouraged him to sign up to Flo. Before Flo, they both felt that mum was constantly ‘nagging’ her son to take his medication, resulting in some tension and not being successful.After using Flo, the patient reported that his compliance improved as it felt ‘less like a parent nagging’. His mother has asked if he can continue to be supported via Flo ready for when he starts at University in September - 

patient quote

“I’m scared he will not take his medication when I am not there to remind him – can he go on Flo again?”.

Patient 2) Flo also helped an elderly patient demonstrate greater awareness of the importance of taking his medication and to reduce his anxiety associated with this. The patient used Flo to be able to prompt and then confirm that he mad taken his medication as prescribed. 

Being able to confirm, in real time, that medication had been taken revealed an additional benefit above reminding and encouraging the patient to take the original desired action. One morning after being unsure if he had taken his medication or not the previous night, the patient was able confirm with his nurse that he had as he could not remember. This avoided the possibility of side effects associated with medication either being missed or being taken again in error. 

Patient 3) One patient who suffers from mental health problems regularly forgot to take his epilepsy medication resulting in reduced symptom control and associated side effects. The patient’s specialist team subsequently identified him as requiring additional support to improve his compliance and discussed Flo as an option with the patient. Behaviour post introduction to Flo demonstrated dramatically improved compliance during his 12 week interaction with Flo. 

However after the 12 week support ended, it became clear that the patient had reverted back to his behaviour pre-Flo and was frequently forgetting to take his medication again. The patient therefore asked the team if he could continue with Flo’s support in receiving daily reminders but over a longer period describing how he felt better with Flo’s support and the impact this had on reducing his anxiety.

A specialist nurse also uses Flo to prompt patients to ensure they arrange to have their blood test every 2 weeks and send their results to Flo.As a clinician, she finds this very reassuring and is able to see trends in blood results and intervene earlier than she could before Flo.


Newcastle Hospitals have reported success with improving the continuity of care received by patients, by utilising Florence. 

outcomes include

  • Florence is making patients feel more reassured that their own healthcare team will be made aware of any admissions, regardless of where in the region that admission may be 
  • Continuity of care is ensured

Case study using one patient with Chronic Myeloid Leukaemia (CML) 

A patient from another Trust out of the area was transferred to Newcastle Hospitals. On previous admissions to hospital she had experienced issues due to repeated communication breakdowns with her own health care team leaving them not aware of her admission. 

When the patient heard about how Florence could help by allowing her to become involved in notifying her health care team of admissions she was very impressed and extremely keen to become involved. Regardless of where the admission occurs, the Flo pathway allows the patient to contact Flo at any time to indicate that she has been admitted to hospital. Flo then notifies her specialist nurse . 

Thankfully, this patient has not needed to contact Flo so far but has benefited in the knowledge and feels reassured to know that she can at any time.


Newcastle Hospitals have helped teenage patients with type 1 diabetes who are on the Hba1c pathway to achieve better control of their condition by using Florence. 

Younger patients with diabetes can tend to have busy lifestyles and often find scheduling their medication difficult to fit in to their routine without prompting. They can often be unresponsive to calls and visits aimed at educating them about looking after themselves, seeing these as intrusive and not relevant. 

Since Florence’s introduction, patients in this group have been able to dramatically reduce their persistently high Hba1c levels, by utilising a user-friendly solution that fits with a teenager’s lifestyle and improves compliance. 

The outcome of this improved compliance has been reduced and much more stable blood sugar levels which will ultimately reduce the risk of complications commonly associated with long term raised levels. 

Case Study: Increasing Motivation and Engagement with Diabetes 

Flo was used to help a 14-year-old female patient who had been on the High Hba1c pathway for several years yet had not engaged with telephone calls and home visits from clinicians. 

Most days the patient would come in from school, eat and go out with friends without taking her short-acting and long-acting insulin, resulting in persistently high sugar levels and a high risk of developing complications due to diabetes in later life. 

On 3rd March she attended clinic and her Hba1c was measured as 121. After a discussion between the patient and her Healthcare Practitioner, she was enrolled with Flo and daily prompts to take her medication were arranged. Florence gave her the flexibility to change the time of this prompt at a later date to personalise it to her own schedule . The follow up clinic appointment on the 24th April revealed a dramatic drop in HbA1c to 87.as a result of increased compliance with her prescribed medication regime. 

patient quote

“A lot of my friends are supportive. To me Flo was very helpful as it motivated me to check my bloods and have a little more confidence in knowing I am not alone.” 

“I feel I have had more support from home and hospital.”


Newcastle Hospital’s Royal Victoria Infirmary (RVI) are reporting increased confidence and safer surgical scheduling for their patients with Parkinson’s Disease. 

For these patients undergoing deep brain stimulation surgery to help control their tremor, a battery pack is implanted into their chest to power the electrodes connected to the brain. As with all batteries, they have a finite life span, lasting between 12-36 months depending upon individual settings and when they run out, surgery is needed to replace them. 

Parkinson’s nurses at the RVI were discovering that the battery level for too many patients was running down to a critical level but not detected in a timely manner. This was leading to the avoidable need to schedule emergency surgery to replace the batteries, a time-consuming task for nurses and a negative experience for patients. To help mitigate this risk, Parkinson’s nurses would arrange review outpatient appointments solely to monitor patients’ battery levels. This of course led to patient travel, time off work and increased demand on an already busy outpatient clinic. 

The team identified that Flo could support the timely identification of a deterioration in battery life to mitigate the need for routine clinics and at worst emergency surgery. Patients are now offered the opportunity for Flo to prompt them to confirm their battery level every 2 months with nurses being notified when a patient’s battery level drops below a defined measure. This allows elective surgery to replace the battery to be organised in good time, and provides reassurance for patients. 

Case Study: Supporting Safe Surgical Scheduling: 

In 2006, a female patient underwent deep brain stimulation surgery. Prior to being supported via Flo, the patient had attended twice in 2014 solely for a battery check. 

The patient was introduced to Flo to support the timely identification of deterioration in battery life on 3rd February 2016 and subsequently on 5th March 2016 a notification was generated by Flo indicating that her battery was running low allowing both the patient and her nurse to be aware and keep a close eye on the battery level over the new few days. 

On review, the patient and her nurse agreed to schedule battery change surgery for 16th March 2016 as Flo had highlighted that the battery was deteriorating much more rapidly than expected. The patient subsequently underwent her elective surgery on 24th May 2016 and her nurse was able to contact the battery supplier regarding the issue with premature battery depletion. 

As a result of the successes achieved with Flo, the Parkinson’s team are extending their use to include monitoring blood results for patients receiving ‘Tolcapone’ treatment (which can be toxic to the liver).

patient quote

“Flo is working fine. It takes all the worry out of wondering if my battery is going to go flat and I am going to be left high and dry. I know that she is going to text me every two months, to check up on me and my battery levels, its just one less thing to worry about. Many thanks”


Demonstrating diffusion beyond original development, a gestational diabetes pathway supported by Florence, first developed by Dr Rahul Nayar and Mr Kim Hinshaw at City Hospitals Sunderland, has now been adopted by clinicians at Newcastle Hospitals Royal Victoria Infirmary (RVI). 

At the RVI, Florence is empowering women, providing them with support to become more involved and engaged with their condition. By utilising accessible communication, Flo is breaking down common barriers to communication, particularly with patients for whom English is not their first language. 

Patient feedback to date suggests that most feel Florence is easy and convenient to use, increases confidence in managing their diabetes, saves them time and that they would use Florence again if they developed Gestational Diabetes Mellitus (GDM) in subsequent pregnancies

outcomes include

  • Florence is reducing call times to women with GDM proving to be cost effective and allowing nursing time to be managed more effectively 
  • Capacity has now been generated to dedicate to women who need the most support. 
  • Women are reporting that they are more aware of their blood glucose levels 
  • Patients are being communicated with in real-time, enhancing patient safety and pregnancy outcomes 
  • Florence is helping the Trust to work in partnership with women. 

Florence is used to enable safe monitoring of maternal blood glucose levels at home for women with GDM. Once consented, women are prompted twice daily to take and send their blood glucose readings to Florence. When two high results are recorded, women are then prompted to make contact via phone with their Diabetes Specialist Midwife or Nurse and discuss their results and determine what changes can be made or whether treatment is necessary. The Health Care Professional also receives an email notification of the result, allowing them to then make contact with the woman at this critical point.

patient quote

“Florence helped me monitor my diabetes and keep record of BG readings. Also vital saving time and made it easier than ringing twice a day” 

“Highly recommended” 

“Fantastic because I can just use my phone and it is reassuring knowing that my midwife can access my results any time” 

“Very impressed with the Florence system – found it very supportive.”

#Epilepsy #Chronic Myeloid Leukaemia #Paediatric Diabetes #Parkinson's Disease #Gestational Diabetes #Newcastle Upon Tyne Hospital

Keeping it simple helped to change patients lives for the better

posted 19 Aug 2016, 09:02 by Hollie O'Connell   [ updated 25 Aug 2016, 06:23 by Philip O'Connell ]

NHS Stoke-on-Trent 
Clinical Commissioning Group 

Ann Hughes 
Practice Nurse and Telehealthcare Facilitator 

25 August 2016 

Keeping it Simple with Flo - 
Ann Hughes 

Technology is rapidly advancing and can offer all sorts of useful solutions that many of us use already in everyday life but I would be the first to confess that I am a complete technophobe. Therefore, any new technology that I am going to use and recommend to my patients has to be easy to use and understand.

Florence (Flo) became my friend a few years ago and she has provided a simple way for me to help my patients to look after their own health better.  At first I was cautious but soon realised that Flo was easy to use, intuitive and I could see how she would help.  I initially used some existing protocols but as my confidence and experience has grown I am now customising some aspects to personalise the outcomes to individual patients.

Here are some examples of when keeping it simple helped change things for the better for my patients:


A worried parent came to me for help to get her teenage son to comply with his asthma medication better. There had been a lot of arguments between them at home as he felt she was nagging him about it all the time and thought that, now he was older he knew better and didn’t need to listen to her. 

I suggested that Flo could help to both remind him to take his inhalers regularly and to send friendly, educational messages which would help him to understand why this was important in relation to making his condition better. Mum thought this was great as it would be ‘Flo’s job’ to remind him and not hers, removing that tension. The son was happy to receive Flo’s messages as using his phone was part of his normal daily life and wouldn’t make him stand out as different at school. 

On review a few weeks later Mum said she had not once needed to remind him to take his inhalers and that she had noticed that he needed his blue inhaler less as he was taking his preventative inhaler correctly and regularly now. 

The son found Flo’s interactions discreet and useful and the educational information he received was helping him to understand asthma better and was delivered in a way he found interesting which increased his compliance.

The rows between son and Mum had stopped, life was better for both of them.

Pre-Operative Hypertension 

When an elderly patient went for her pre-operative assessment at the hospital her blood pressure was found to be very high which could have meant postponing her operation. She had been advised to contact her GP surgery for monitoring. 

Instead of the patient coming into the surgery for blood pressure readings weekly and probably meaning rescheduling of her operation, I suggested using Flo to allow her to monitor her blood pressure herself at home and record real time readings. I showed her how to use her blood pressure monitor and as the patient didn’t have a mobile phone I arranged for her son, who lived with her, to send and receive messages from Flo on her behalf, which he was happy to do. Over the next four days the patient’s readings were sent to Flo twice a day with the appropriate advice depending on the patient’s blood pressure. 

On reviewing the patient’s readings, I found they were all normal and I was able to send a copy of these readings, together with a short explanation, to the pre-operative assessment team and the outcome was that they were happy that the patient did not have hypertension and the operation could go ahead as scheduled. I messaged my patient via Flo, to say everything was OK and to reassure her the operation would go ahead as planned. 

Using Flo ensured a quick solution, allowing the patient to provide all the necessary data easily from home without having to return to the surgery for a follow up appointment and also prevented cancellation of the operation or the prescribing of unnecessary medication

Treating Hypertension 

Flo is producing great results in our practise for helping to diagnose patients with hypertension and to facilitating the start of medication quickly and easily. 

When a patient visits the surgery and has a high blood pressure reading taken, they are immediately offered Flo to monitor this for themselves at home. Patents are prompted by Flo twice daily to take their own blood pressure using the monitor provided and to then send back the readings. After a few days these are reviewed by our nurse and if found to be within a normal range, a message is sent from Flo to reassure the patient that everything is fine, to stop the recordings and to return the monitor at their convenience. This is quick, simple and gives reassurance to the patient. 

If on review the readings are found to still be high, the patient is again messaged by Flo to ask them to come into the surgery to collect a prescription. This is supported by educational messages to explain the hypertensive treatment and possible side effects to look out for which patients find reassuring. The patient continues to be prompted to send regular readings which will show if the medication is working or upon review dosages may need to be altered. This simple solution is efficient and means that the patient is commenced on the correct course of action quickly and reduces the number of follow up visits to the surgery, so freeing up clinical time to see other patients. 

Patients who have used Flo report feeling supported and reassured by the messages and appreciate the simplicity and time saving.

Intellectual Property and Copyright of Simple Telehealth (Florence) pathways, protocols and content.

posted 21 Jul 2016, 06:23 by Philip O'Connell   [ updated 13 Sep 2016, 05:40 ]

for patients, not profit  
Phil O'Connell - Jackie Smart

Phil O'Connell 
Creator of the NHS's Simple Telehealth & Florence 

Jackie Smart 
TECs Consultant 

25 July 2016 

With the continued spread and adoption of Simple Telehealth and Florence, our NHS members have asked for clarification on the ownership and use of Florence content and related materials to prevent misappropriation outside of the intended purpose.    

Over time members of the Simple Telehealth Community have developed Florence and Simple Telehealth specific pathways, protocols and content, and without any thought of payment they have made them available to other like minded members of the Simple Telehealth Community to use safely with Florence for their own patients.

It is the intention of contributing members that their efforts  are protected to be used safely within the unique Simple Telehealth & Florence environment and that their work is not misappropriated for use outside of the Simple Telehealth Community.  

Materials1, typically interpretations of best practice guidance and/or NHS pathways are developed by individual members or collaborating members specifically for use with Florence.  The development of these Materials1 may also involve the use of Simple Shared Healthcare's specialist knowhow and methodologies and the knowhow, designs and methodologies licensed for use by Simple Shared Healthcare by NHS Stoke-on-Trent Clinical Commissioning Group.

Ownership of Foreground Intellectual Property contained in Materials1 developed for Florence resides with the member's organisation and ownership of background Intellectual Property resides with the originating author under associated terms of use.

For clarity; To protect members interests, use of Materials1 by non-members of the Simple Telehealth Community is PROHIBITED, but members of the Simple Telehealth Community may freely use contributed Materials1 to benefit their patients through Florence via the Creative Commons None-Commercial Licence.   CC BY-NC-SA 2.0 UK )

1 Florence and Simple Telehealth specific pathways, protocols, templates, content, user guides, promotional material, patient information et al

For more information contact phil.oconnell@simple.uk.net

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