Integrated Primary and Acute Care System


The drivers for the Better Together Mid Nottinghamshire telehealth project are familiar across the health and care sector. More than 15 million people in England live with at least one long- term health condition, accounting for 70% of NHS spending and representing 55% of GP appointments and 77% of inpatient bed days. The project was adopted in response to widespread interest from clinicians in tackling these issues. The Florence telehealth tool was chosen, in part, on the basis of previous successful projects.


Florence (or Flo) is an automated telehealth tool that uses SMS text messages to help people manage their own health conditions at home. The tool works with a patient’s own mobile or landline telephone together with biometric devices such as blood pressure monitors. The system sends text messages to prompt patients to stick to tasks that they have agreed with their clinician, such as sending in vital sign readings.
Flo sends timely and appropriate reminders such as medication prompts. Patients reply to Flo via text message and the Flo system responds in accordance with protocols agreed by the clinical team.

‘Florence’ and ‘Flo’ are registered trademarks of NHS Stoke-on-Trent CCG. Once an NHS organisation licences the system, all clinicians in that organisation can use the tool, which consists of system access and a text message bundle. Clinicians have also been able to access a clinical community of NHS colleagues to share learning, best practice knowledge, evidence and training. This is led by Shared Healthcare Ltd,
a not-for-profit social enterprise operating under an NHS Simple Telehealth licence.


The Nottingham Assistive Technology Team, which sits in the Health and Wellbeing Hub, had already started to make great strides with the roll-out of Flo in 2012, beginning with the heart failure services. 

This project resulted in a 35-48% reduction in nurse visits. It was also clear that hospital admissions were being avoided thanks to detecting signs of deterioration earlier.

An evaluation by the University of Strathclyde showed that in 2013/14:

  • for the heart failure nurse team, home visits halved ADHD clinic appointment reminders reduced
  • non-attendance at clinics from 55% to 0% among patients using Flo
  • use of Flo with pre-operative patients reduced the costs of cancelled surgery. Pre-operative patients found to have high blood pressure used Flo to send in twice daily blood pressure readings for a week. Eight patients (73%) had high blood pressure. A cancelled surgical procedure costs
    £232 meaning there was a £1,856 cost avoidance for these patients.

Findings for the 12 months before and after adoption of Flo show a significant reduction in the number of GP consultations for patients with high blood pressure and lung disease. For every patient group at least 80% of respondents reported less frequent usage of GP services after they started using Flo. As a vanguard, Mid Nottinghamshire has built on these successes to accelerate the pace of the programme.


The involvement of patients in the work has been essential to ensure end user satisfaction. Interestingly, patient feedback from 98 patients at Sherwood Forest Hospitals NHS Foundation Trust orthopaedic service showed that 86.7% of 32-90-year-olds using Flo strongly agreed or agreed that it is easy to use, suggesting that this type of technology can be accepted and used by people of all ages.

Parallel to this, the introduction of telehealth technology has required a culture change among staff. A COPD nurse in the Newark and Sherwood team has pointed out: “there is a culture change that clinicians need to go through. We have to stop unnecessary visits to patients and allow Flo to
support patients on their behalf”. Key to driving the implementation of the technology forward has been to engage a clinical champion who can advocate the use of Flo among their peers.

The team have also learned that there is a need to align any improvement to national standards, targets and local area agreements.


The Connected Nottinghamshire programme was set up in 2013 to create and deliver the local digital roadmap for Nottinghamshire. They have been working with the vanguard and CCGs in Nottinghamshire to make sure that everyone is connected and work isn’t duplicated. The programme’s strong and robust partnership, shared vision and shared strategy, have contributed to the success of Flo across Nottinghamshire, as well as the development of a local digital roadmap to support the STP. 

Since the heart failure trial, Flo has been deployed across a range of areas, including diabetes, hypertension and blood test reminders. Flo is continuing to be rolled out across Nottinghamshire and across even more types of health conditions including pain management and a project looking at cancer pathways and use of telehealth cognitive behaviour therapy.


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