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Common questions and answers for Simple Telehealth (STH) and Florence (Flo)

Is STH really an NHS initiative?

Yes.  Simple Telehealth was designed and developed by Phil O'Connell who assigned the Intellectual  Property to Stoke on Trent PCT.  Ownership will move to Stoke on Trent CCG after March 2013.

Phil assigned "stewardship" as he calls it, to Stoke for them to use, develop and share the concept  as an NHS initiative for the benefit of all NHS patients.

Some specialised components of the service are provided externally but these are strictly under NHS license.

Who designs content and uses?

The methodology creates an innovative environment in which NHS clinicians can develop and apply the shared knowhow and methods in their own particular field.  The content and its uses are limited only by the vision of clinicians.  However, one condition applies to all who use the system: they must freely share their work for the benefit of patients and the NHS.

Does STH have any external recognition?

To test this NHS concept and design, STH was entered for a number of awards in 10/11 and 11/12.  We started with regional NHS health awards to test the concept for use in a healthcare setting and then moved onto national and international competitions testing both the health application and the technology against some of the best.  We were delighted with the results, picking up awards in every competition entered and having the methodology discussed in publications and media.



STH Health Awards2



STH Industry Awards


STH media

How is STH different from other "telehealth" systems?

There is a general misconception that "telehealth" is about remote biometric monitoring.  However, telehealth actually covers a large range of "tele" approaches to provide convenient and potentially effective ways of engaging with patients.  Its about getting health to catch up with techniques and methods already in everyday use outside of health.
Technology wise, telehealth spans from telephone and Skype consultations at one end through to robots helping clinicians to do ward rounds in remote locations.   From a clinical perspective it ranges from just a tool such as a telephone through to automated clinical decision engines using validated clinical protocols.  There are of course many mixes and matches creating a rich but immature marketplace and the Department of Health are working to make it less confusing and  easier to access.
STH puts patients in control and is targeted at bringing clinicians and patients closer together by helping patients to help themselves to improve concordance and compliance with thier existing pathway/treatment though a mix of automated and interactive communication.  At the same time it should introduce benefits for the clinicians using the system and techniques without increasing the cost/time of providing the healthcare service.
In contrast to this, the trend with established triage based telehealth providers seems to be moving towards "fully managed services".  We are therefore moving in significantly different and opposite directions which should provide clarity and a suite of complimentary services for commissioners to consider.
Commissioners have described STH is as a "lite touch" telehealth service and this is a reasonable label association to show where STH sits in the spectrum of telehealth services.
STH is instinctive & intuitive and quick & easy to use by both patient and clinician.  Designed to be deployed immediately taking less than 20 seconds to enrol a patient, which can be done by the responsible clinician during the consultation.
Another interesting point that makes STH stand out is that following appropriate governance procedures, data can be shared with a patients healthcare team irrespective of NHS organisational boundaries.
Also, as an NHS initiative for the benefit of all, it is low-cost and can be used through a patients own mobile phone.

Does STH compete with other "telehealth" systems?

STH should compliment other telehealth services and can happily work alongside them.  "Bio-metric remote monitoring" type systems tend to use a daily triage/monitoring approach which targets higher risk patients for prevention of admissions.   Even within this sub-group there is a large range of services, some offering basic and inflexible services and others offering sophisticated behavioural change, education and automated clinical management.
So in a nutshell, STH does not compete with other services as far as we are aware as its purpose and techniques are quite different.

Do we need to redesign our service to use STH?

No.  You can use STH in any primary care or outpatient setting to improve the quality of outcomes and to reach hard to engage patient groups without any re-design.  STH helps patents to engage in the existing pathway/treatment to improve the quality of outcomes.
It is fundamentally wrong to design a healthcare pathway around a telehealth service of any kind.   Follow the advice of Sir John Oldham and the national QIPP programme: Design the health system first and only then consider if technology can assist to attain better outcomes.

How much will it cost?

STH is based on a pay as you use model.  To get started £10,500 could cover around 3,000 patients and the first 37,500 messages.
  • £5,500 contribution towards maintaining this NHS community giving access to our shared IP, forums and remote assistance.
  • £2,000 towards the cost of providing Florence
  • £3,000 bundle of SMS for Flo.
  • £0 Training at our Stoke-on-Trent offices is Free!
  • £600 +expenses per day for on-site assistance/training.*

* New member organisations may benefit from 1-2 days on-site assistance/training to kick start the programme.



If you chose applications that need bio-metric monitors such a Blood Pressure monitor for example;
  • your patient may already own a suitable BP monitor that can be used for home monitoring;
  • you can ask your patient to buy their own monitor for use with STH.  Some localities have made special arrangements with local pharmacies to stock suitable devices.
  • your local procurement team can supply a suitable model or we can recommend high specification but low cost devices and put you in touch with a not for profit supplier.
If you do use monitors, then you should factor in the cost of a device against the business case, limiting the "life" of any device to the length of the manufacturers warranty.
Although it is desirable to re-use devices, you may find that it is a lower cost approach to gift the device to the patient as recycling a low cost device through an infection control process may cost more than a new device!
It is usually the patients own clinician who will show them how to use any equipment properly to get the best results rather than outsourcing this crucial activity.

Does it cost my patients anything?

No,  we have provisioned a "free to text" service on every UK mobile network so patients are not charged to use the service whether they have a mobile phone on contract or PAYG.

Are we restricted to numbers of patients, clinicians, teams or pathways?


What about patients who can't text or don't have a mobile phone?

Innovative clinicians have developed pragmatic ways to work with patients who can't text or don't have a mobile.   Interestingly, the same methods have been developed independently by very different teams across England.
Firstly, they found that age is not a barrier and many older patients may own a mobile phone, but keep it for emergencies only.  So many will own a mobile and the majority of those will already know how to text.
Others methods developed by clinicians for LTC patients are:
  • to invest 20 minutes to show a patient how to text, which also reduces social exclusion.
  • to work with a patients partner/carer who would be able to interact with Flo via their mobile whilst the patient takes any observations or answers questions.
  • to work with a social care carer who would be able to text on behalf of the patient during routine visits.
  • In one instance where a patient was living alone in a remote rural area, clinicians worked with the patients son, who did the texting whilst speaking to his mum on the phone each day.
  • to "loan" a patient a standard PAYG mobile phone (Florence is free to text)

Technology solutions include the use of a landline telephone (1), the use of a smartphone based telehealth system with bluetooth peripherals (2) and a locked down app on a smartphone (3)

(1) Message Dynamics, (2) Whzan, (3) TellFlo: University of Hull/Stoke PCT

What hasn't worked?

In common with all telehealth solutions, implementation needs the support of senior clinical leaders.  In the early days, our approach meant that we engaged teams via telehealth commissioners, which in some cases put distance between senior clinicians and the project, thereby denying the project essential support.

STH can face recruitment challenges if trying to use it to step older LTC patients down from more intensive/contact based services.  Why would a patient opt to come off a service on which they have become dependent and which provides regular reassuring contact (even if not clinically necessary)? The same teams though have succeeded when using it with patients new to the caseload before dependency is established.

STH philosophy is about NHS clinicians keeping clinical responsibility whilst establishing a clinically appropriate level of interaction and/or monitoring to achieve better and faster clinical outcomes than normal care.  We discourage use of STH to put distance between the responsible NHS clinician and patient and industries outsourced "fully managed" services fill this role better.

Some patients are not willing/able to self manage.

Is there any academically robust "evidence" that STH & Flo works?

Whilst there are many evaluations of STH & Flo underway in localities across England for many and varied applications, we are fortunate to have a paper peer reviewed and published in BMJ Open regarding a service review of its use in general practice for hypertension.

What about clinical and information governance?

STH as an NHS initiative was designed to work within NHS governance boundaries.  In its many implementations it has passed all of the local clinical and information governance tests it has been subject to.  An IG datasheet is available to download.

Is texted, self reported information reliable?

Interestingly, we have found that texted self reported data is probably more reliable than that delivered by automated systems.
There is emerging evidence as to why this might be the case:
Professor of psychology Michael Schrober, University of Michigan:   "it seems that texting may reduce some respondents' tendency to shade the truth or to present themselves in the best possible light"

Checkout "Texting in Health" on our Links page.

How long do patients use STH for?

Because STH is used primarily to assist the attainment of clinical objectives, use is usually limited to appropriate points in a pathway or treatment where STH can be effective, so long term use is the exception.
For some cohorts of patients though, longer term use is desirable and a small number have been using Flo for over two years.   So long as patients and clinicians feel the system is providing a useful and better engagement experience than normal care alone, then use can continue, however patients always have the option to opt-out at any time just by sending STOP to Flo.

What can STH be used for?

The pathways, conditions and treatments that STH can be used in to improve outcomes is virtually limitless.  Below I have listed some of these:
COPD, CHF, new hypertension, hypotension, diabetes type 1, dementia, vascular cognitive impairment, sexual health, retinopathy,  medication compliance, diabetes type 2,  medication titration, orthopaedic,  pulmonary fibrosis, cervical smear, smoking cessation, speech therapy, carers wellbeing, mental health behaviour,  long term hypertension, asthma,  alcohol support, weight management, early hospital discharge, outpatient therapy, acute specialist follow up, long term monitoring, prothrombin time, oximetery review,  asthma, depot injections, pregnancy, pain management, physiotherapy, palliative care, learning disability, oncology, neurology, pediatric asthma, health self-assessment, virtual wards including primary, secondary and community providers, falls, neuropsychology, DNA management, CKD, hypothermic, kidney transplant, learning-disability, gestational diabetes, rheumatology,  asthma, obstetrics, interstitial lung disease, dietetics, depression, pregnancy induced hypertension & proteinuria, urology + many more