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Hypertension and Flo in General Practice; exploring evidence supporting sustainable scale-up of services

posted 28 Aug 2019, 07:50 by Hollie O'Connell



Hollie O'Connell 
Innovation Support Officer 

Karen Moore 
Advanced Capability Lead 


30 August 2019 


Since the early days of our Community of Practice, hypertension has proved to be the most successfully evaluated pathway with Florence.  Following our recent news of Scotland’s £1.2 million Scale-up BP Initiative which will see Flo rolled out nationally over the coming 2 years, we’ve compiled below some key articles and case studies which demonstrate the many sustainable benefits of supporting hypertension pathways with Flo.  These publications have been contributed from all corners of the community and include evidence for the release of appointment capacity and standardisation of care, along with the positive outcomes for patients with better disease control, which has been achieved by combining Simple Shared Healthcare’s unique methodology, Flo’s persona and the utilisation of local clinical best practice.


One of the earliest publications evidencing the influence that Flo had on patients hypertension management was published by NICE in 2012, where key findings were not only a significant reduction in patients BP readings, but also through Flo’s interactions and unique persona, patients benefited from an “improvement in education about hypertension, a greater feeling of support and companionship and flexibility which allowed self-care to occur”.

A service evaluation was also published in 2012 as a BMJ paper with 10 General Practices in Stoke-on-Trent volunteering to measure the acceptability, satisfaction and ease of use when using Flo for hypertension management in primary care.  Overall satisfaction with Flo was very high, scoring 4.81/5.00 at week 13 of the programme with “feelings of control and support” and patients finding Flo easy to use.  Along with this, it was concluded that Flo should be considered for wide-spread implementation for hypertension as “a large number of meaningful readings can be obtained from many patients in a prompt, efficient, interactive and acceptable way.”

Another BMJ paper published in 2012 examined “how efficiently an innovative, simple and interactive blood pressure (BP) management intervention improves BP control in general practice.”  This study gathered data from patients who received treatment as usual and patients who received Flo as an intervention.  Results showed that intervention patients had a greater reduction in their BP readings and due to there being significantly more readings, there were more medication changes as clinicians were able to access more accurate readings and titrate medication appropriately.  However the highlight of this study was seen when Flo’s intervention stopped.  Patients from the control group not using Flo, over time returned to their baseline uncontrolled BP readings, whilst those who had received an intervention from Flo continued to control their BP (as shown in diagram below), demonstrating sustainable behaviour change and continued self-management of their hypertension.


Later in 2015, a further BMJ paper was published focussing on the AIM (Advice and Interactive messages) project which included 425 primary care practices in England evaluating a number of pathways in Flo including medication reminders, smoking cessation and hypertension diagnosis/monitoring, where the impact and acceptance of Flo for patients and professional users was assessed with positive results.

More recently, NHS Grampian published a 90 day study where “the evidence shows that home BP monitoring using Florence improves efficiency for practices, supports improved clinical decision making, and delivers a positive patient experience” which provided patients with multiple benefits including 50% of patients avoiding ambulatory monitoring.

Highlands also evaluated a number of applications in Flo which included their use of hypertension diagnosis, where:
  • 86% of patients found Florence easy to understand, and felt that Florence had helped them manage their own health condition.
  • 76% found Florence encouraging and supportive, and felt that Florence had enhanced their experience of NHS Highland healthcare.
  • 71% found Florence motivating and informative, and felt that Florence had helped increase their independence.
  • 67% felt Florence had reduced the need for them to attend clinic appointments.
On the journey to Scotland’s Scale-up, in 2017 NHS Highland shared their success at the World Congress on Integrated Care’s ‘International Conference on Integrated Care’ in Dublin, with Ian Trayner also presenting the outcomes from NHS Western Isle’s redesigned hypertension pathway, demonstrating that Flo can be used sustainably at scale with great effects.

NHS Lanarkshire’s large-scale implementation of Florence was supported initially by a 90 day rapid improvement study focussing on Flo’s impact on appointment capacity and clinical decision making.  This study along with the soon to be published outcomes of NHS Lothians Scale UP BP programme provided valuable evidence to support the decision for Scotland to scale-up with Flo nationally.  Some of the benefits found included:
  • Using Flo helped improve efficiency by reducing the amount of appointments needed and releasing clinical time.
  • Flo helped support clinical decision making and enabled faster clinical decision making.
  • Patients found Flo easy to use to monitor their BP and would use Flo again.

Alongside the substantial quantitative evaluation, qualitative evaluation has also been captured by a number of organisations capturing how patients and users feel about their experience of Flo.   Jane Freeman - Health Secretary Scotland commented: 

“This technology [Flo] brings significant benefits to patients. It enables them to have more control over how they manage their condition, and greatly cuts down on the number of appointments they have to attend.”

Below is a selection of patient comments about their experience of using Flo and how she has contributed to better management of their hypertension: 

“The system [Flo] is so easy to use and has made all the difference to me and my family” 


“I have found using Flo really good, the reminder and what to do with blood pressure is too high is very useful as there are times when you forget that it is time to check the blood pressure and you get a gentle reminder. Doing the BP at home is less stressful as it is a more relaxed environment”


“I liked being in control of my monitoring. I also know a lot more about blood pressure”


“Being offered the use of Florence was a brilliant alternative [to attending appointments] – and I think the hassle free-nature of it, without having to commute and take time out of a busy day, probably gave a truer reflection of my day-to-day readings.”


The widespread adoption across our Community of Practice with hypertension pathways, would not have been possible without the robust governance arrangements.  Florence is NHS IG ToolKit level 2, ISO 9001, ISO 14001 and ISO/IEC 27001 certified and is fully GDPR compliant providing assurance to clinicians around the safety of patient data and it’s transfer via the newly developed API which enables Flo data to be integrated into local clinical records.