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Florence and Telehealth from Dave Sanzeri and Chris Chambers from Stoke On Trent CCG

Date posted: 25 May 2017

Dave Sanzeri and Chris Chambers are both big influencers in the NHS and especially in Telehealth. Dave is Head of Commissioning at Stoke on Trent CCG and Chris is Stoke on Trent CCG’s Telehealth facilitator. I wanted to get an insight into their thoughts on Telehealth, Florence and the future of digital healthcare and they offered to arrange a call with me to share these. I’d like to share their thoughts with you.

What gave Stoke the idea for Florence?

Dave: You need to go back 7 years for when the idea of Simple Telehealth was originally presented by Phil O’Connell the inventor of Florence after some work he’d been doing with people with long term health conditions. Stoke on Trent’s PCT chief executive saw the potential in it and he bought into the intellectual property by making resources available to Phil so his idea could be further developed and tested. The PCT entered an agreement with the service provider, Mediaburst and Phil O’Connell and then made its Clinicians available to help develop the protocols. It takes a great deal of vision on behalf of people to see there may be potential in something like this. At the time this was a significant advance, everything at the time was face to face, hands on, and required people to sit for an hour before they got to see a GP or clinician. Remote monitoring of people was a clumsy business, it nearly always invited a piece of kit to be wired into your home. Florence allowed you to do it on the go and it made it a light weight approach to people participating in their own care rather than like I said a really clumsy and restraining way in which we were doing before.

How does Florence help patients with long term conditions?

Dave: Florence has been a bit of a trail blazar on this. Florence opened up participating in your own care for a whole raft of people. For example, if you had a debilitating respiratory condition prior to Florence you had to be at the complex care end before you got any telehealth support. What the introduction of Florence did, was to move telehealth from a reactive, ‘let’s wait until you’re really sick before we put this in’ to one where we can actually say ‘you’re at a position now where you understand what’s happening with your health and what you’re like when you’re well and when you’re not well’. The patient understands their respiratory state, blood pressure, sputum colour or whatever it is that the protocol on Florence asks them to look at and report back on.

Florence is being introduced much earlier now, at the point where patients are still ambulatory and the idea is it will fit in with the way people are living their lives rather than making it an imposition on their lives. I remember going to visit someone when I first came to Telehealth and they had a big box by the phone and it was all about being in the house and it actually reinforced to them that they were unwell. Whereas, Florence says, ‘Have you got a minute, wherever you are?’ That idea of measuring some of your biometrics or responding to a motivational message or simply getting something that says tell us have you done this today? It’s not intrusive. When I used to go to the earlier demonstrations on how this works, one of the USP’s of Florence which the other telehealth health systems didn’t have is that most people won’t ignore a text. If your phone goes ‘ping’ you think ‘what was that?’. That’s where the interaction with the individual comes in and that’s why it’s proactive and it shares care with the person. We’ve known right from the off, this is about people participating and being responsible for their own care.

Who will benefit the most from Telehealth, patients or the NHS?

Dave: It’s got to benefit patients first. The benefits of Florence come for the individual first and then because the individual is participating more in their health and taking more responsibility of their own health and importantly then using health services differently, that’s where the benefit for the NHS comes from. You don’t get any benefit simply by someone signing up to Florence it’s how their behaviour changes as a result of being on Florence, that’s where the benefit package starts to be realised. Putting someone on Florence with, for example COPD helps the patient understand their own body resulting in them using their rescue medications without a prompt. It’s been proven that someone on Florence’s COPD protocol is more likely to take their rescue medications than someone not on Florence. Going on their rescue medications may mean that instead of being at the hospital 3 or 4 times a year they may just have to go once. Florence helps confidence grow in patients so they can participate in their own care. Patients on Florence recognise the time is right to take their rescue medication so they take it a day or two earlier than they would have done before. In those two days they don’t become anywhere near as ill as they would have been after another two days.

What’s the one key thing you would advise a clinician on the benefits of telehealth?

Dave: I would say there’s a rule of three, in no particular order.

Most GP’s will tell you that care has to be a partnership with the patient. What Simple Telehealth does is form a collaboration in care between the GP and the patient. Florence also allows an opening up of that relationship so it includes other people with a role to play. We’ve always said, having a multidisciplinary team approach to the care of a group of patients is always going to be much easier if the clinicians and the patients both have access to a range of indicators which show how a patient is progressing, how well they are and what the triggers are that cause any response in their health.

Number two, is it saves time when used as an integrated part of a care plan. When you introduce something like Florence, people focus on the time it takes to put the patient on it but if Florence is used to understand a patient’s blood pressure or respiratory cycle or to understand why a patients struggling to give up smoking or why can’t they lose weight, it eventually saves time. If a GP wants to know how a patient has been over the last week, it’s difficult to do that if the only 2 blood pressure readings you have are the one you took last week and then the one you’re going to take today. Florence will ask them to take and record their blood pressure twice a day or to weigh themselves every morning. Recording the readings over a week means if there’s one which has been recorded wrong, it’s going to show up but generally you should be able to see a trend. That means that what you want to discuss with that patient can be richer in a consultation. What it may also allow you to do, instead of having the patient in twice in a period of two weeks, it may allow you to only have them in once.

The third is, it supports the model of care. If the model of care was we want to make better use of information, we want to be evidence driven, we want patients to participate in their health, we want it to be much more anticipatory and prevention linked and so on, introducing Telehealth and in particular introducing a Simple Telehealth system like Florence supports that. When it’s used effectively, it’s integrated into a plan and clinicians and patients know what it’s there to achieve. Florence means patients start to use medications or exercises or stress relief techniques, whatever it is their clinician has taught them rather than just putting their stress relief technique on the shelf and out of embarrassment telling the GP they did absolutely everything they were asked to do. Florence is much more likely to support you so the model of care gets delivered.

Chris: Florence is now a structured thing to do. An obstacle is, even though clinicians now have this gadget, they don’t want to change how they are and they haven’t embraced it as part of how they deal with things. In small pockets they have but not across the board on large. We need a complete cultural shift to help with the implementation of Flo. Some places it has happened, some of the practice nurses embrace it and they think it’s fantastic. One practice nurse I know has over 50 patients in her practice but many others use it for a bit and then found that they had other things to do, a lot of pressure on and they’ve dropped off using it. It’s got to be part of the whole plan, the structure and everything. And if it’s used correctly, it could work across general practice, community care and secondary care and everyone could look at this patient and pass them from one to another as the patient progresses or regresses and it’s a fantastic tool in that way. When you talk to the clinicians in all of those different places, they don’t usually talk to each other and they haven’t yet embraced the fact that Florence and the world generally might expect them to work in a different way. So, we’re hampered particularly locally here by some entrenched isolationist policies by different professions. If anything, it’s driven higher quality by at least opening the idea that there’s this potential. Rather than being handed a leaflet and told to get on with it, they actually participate more as a result of having Flo and it’s a real tool for self or shared care and I think it’s fantastic.

What are the challenges faced?

Dave: Florence has come a very long way but it’s got a long way to go to reach widespread implementation. While there are 3 reasons why clinicians should and are using it, there are 3 reasons why they aren’t.

The first one is the interoperability with other systems. GP’s will want Florence and access to what Florence tells them to come at one click to a system they’re already in.

Number two is people don’t understand Florence and what Florence can do. I think when Florence was created, instead of picking 2 or 3 protocols, there was a bit of an explosion of protocols. This means Florence can’t be marketed as doing the protocols which it does brilliantly because the menu is almost too big. Such a wide choice, no choice at all.

The third one for me is, we did a lot of work on getting people on to Florence but we didn’t do a lot of work on getting them off it. We talked about the outcomes from Florence but we never made the link between the outcomes being achieved and how you step people down from it. Florence would be best saying, do X,Y and Z and when you get to Q that’s when you discharge the patient. Getting someone onto Florence is great but equally getting them off it is important too.

Chris: There are other issues as to why people don’t continue to use it. I don’t think nurses factor in enough time to look at the results on the screen of the patients. The nurses feel they have zero time to check these.

What’s the future of Telehealth and Florence?

Dave: It’s only constrained by our imaginations for me. Florence and what it has to offer individuals is only constrained by our lack of imaginations. Where’s ‘my Florence’ which doesn’t require me to go on it with a GP? Why can’t I access the protocol I want, for myself? If I want a weight loss protocol, why can’t I be told by someone – why don’t you try Florence? It’s not a clinical protocol, it’s a help protocol. I’d like to see people signing up for a protocol for weight management and telling it what their targets are like they would with a GP. Why can’t I use it to give up smoking? This industry now has uncontrolled expansion. I have my Fitbit and when I get home it will tell me all sorts of things about my day. Florence does so much more than that but I’d like to be able to attach it to something like a Fitbit programme. A Fitbit in itself may change my behaviour slightly but it doesn’t have that interaction with me that Florence would have. You could have Florence as a clinical tool where there are some quite clear clinical outcomes and so on. You could have Florence Light, where by you introduce people to a limited number of protocols where by you get people using it and they might then move to a more controlled Florence later and then what about a ‘Florence for Me’ if I don’t need clinical supervision? If I’ve not been feeling well, I could then go to my doctor and say, actually my blood pressures been quite high for a while or I’ve been monitoring my weight and it’s looking like this.

A massive thank you to Dave Sanzeri and Chris Chambers for their time and for sharing their thoughts with us.

If you’d like to chat more about Florence, please get in touch.