At HTN Now: Digital Primary Care, we were joined by Dr Jonathan Sergeant, Chief Medical Officer of Generated Health, and Dr Matthew Davis, clinical pharmacist within the medicines optimisation team at NHS Bedfordshire, Luton and Milton Keynes (BLMK) ICB.
Generated Health run Florence, an intelligent messaging platform that communicates with patients via SMS messaging in between clinical consultations. Jonathan and Matthew joined us to discuss the venture between Florence and BLMK ICB, with focus on their blood pressure management programme BP@Home.
On Florence, Jonathan said: “It has a great impact in supporting people to care for themselves and provide relevant monitoring needed by clinicians, but also it reduces their workload – they are the two key things that we need to try and achieve. We use text messaging through algorithms, so the patient feels like they are being communicated with and they feel that they have structure between consultations with the clinical teams.”
Matt has spent six years working as the cardiovascular and stroke lead within his trust, a role in which he saw firsthand the effect that strokes and conditions such as MI can have. “I recognised that there was a lot that could be done around primary prevention for these conditions,” he said. “A job came up within Bedfordshire CCG, now ICB, looking after an area of GP practices. It seemed like a good opportunity to take some of my learnings from the hospital and see how we could increase that primary prevention for things like atrial fibrillation management and hypertension.”
Florence within BLMK ICB
Matt’s role involves spending time within the GP practices he looks after, to gain primary care experience and develop understanding of the management of long-term conditions along with potential problems that can arise. His team also work at strategic level and work to address issues on a large scale, with the aim of implementing strategies across the whole ICB.
Jonathan explained that there are currently lots of practices working within their primary care networks to try and solve these problems alone. “One of the things that has been really good in working with Matt is that he is able to focus on some of the real barriers to technology implementation from an ICB level,” he said, “helping lots of very busy teams with their time constraints.”
Alongside direct work with a small number of practices, Matt’s team works with a wider footprint of 94 practices across BLMK.
“There’s a very big variation in terms of things like hypertension management,” he acknowledged. “As I think most ICBs will recognise, we’ve seen a drop-off in terms of hypertension management since the COVID pandemic.
“We have a population of around 140,000 patients with hypertension. We’ve got a wide gap between those we have managed to target, compared to our ambition and the NHS ambition as well. Significantly, we also see a very big variation in management between practices when we look at the data. So we’ve got a number of problems that we need to look at and that we are trying to address at the moment.”
Challenges and tackling them
“I think the pure quantity of patients is a main challenge,” Matt said. He noted that staffing levels can tie into this, with low numbers of GPs and healthcare professionals making it difficult to keep in contact with patients and bring them back into practice for their checks.
“If you’re sending 200 or 300 letters each month to patients around blood pressure checks, that has a huge impact on your workforce,” Matt pointed out.
In addition, he highlighted that there can be inertia around hypertension management, providing a cultural issue to tackle.
To underline the challenge, Jonathan shared a diagram on BLMK’s hypertension cohort, showing the estimated additional number of patients with recorded hypertension whose blood pressure needs to be managed to target in order to meet ambitions. It is available to view at 08:01 on the video below.
Jonathan commented on the current pressure on general practice and the “sheer volume of workload” that can happen in this area, and said: “One of the key things with working with technology like Florence is having more communication with the patient in between consultations. It’s about helping patients manage themselves and provide information and provide blood pressure back to the practice.”
Starting the project
Within BLMK ICB, three key areas had been identified for improvement within their hypertension pathways as part of their BP@Home project.
“We wanted to improve the efficiency of the process around your blood pressure checks and reduce the workload of practices, so that we can focus more on those patients that actually need interventions,” Matt said.
The third area of focus is around trying to empower patients to manage their hypertension themselves and give them more ownership over their health.
“We have to bring people in for an annual BP check, but shouldn’t we be encouraging people to check their own blood pressure quarterly through the year, or every couple of months?” he asked. “If someone is hypertensive and you are only picking it up at once a year, they could be hypertensive in six or nine months and the damage is done.”
Touching again on the inertia challenge, Matt added: “Then there’s work around motivating people to manage their blood pressure correctly – how are you providing positive messaging to support them in knowing that they are doing the right thing?”
In addition, when seeking technology to support them in this, Matt highlighted how it can assist with newly diagnosed patients. “We have been working on a new streamlined process and guidance locally to minimise the number of contacts and get patients self-managing themselves as part of the early hypertension management protocol. Then we need to follow them up after a few months just to keep an eye on them and make sure everything is working as it should.”
As part of BP@Home, Matt explained, his team work closely with the local Academic Health Science Network. The AHSN had explored available technology and performed an evaluation.
“Florence seemed the best fit for our needs,” he said. “That’s why we picked Florence as our technology of choice.”
In designing Florence protocols, Jonathan said, reducing workload for general practice staff is always key. In addition, Florence places strong focus on empowering patients to self-manage their care and acknowledges that there is no one-size-fits all when it comes to patient communication, as different people can face different problems such as engagement, medication adherence or education around the condition.
“What did you start to notice in terms of getting efficiencies for your administration and clinical teams, in the initial phase?” Jonathan asked.
“We’ve worked with a few practices and a PCN to implement a couple of different protocols through Florence,” Matt explained. “We’re running a diagnostic protocol that asks patients for one-off blood pressure check, and if the figure is high then it prompts them to take a seven-day check. If it’s not high, Florence messages the patient back and tells them that everything is fine.”
Jonathan shared an example of the diagnostic protocol at 14:19, illustrating Florence’s messaging from an initial welcome message once the patient has been signed up by the trust to requests for checks to acknowledgements and further actions.
This supports the team in tackling the volume of their caseload, Matt said; with Florence automatically following patients up, staff do not need to replicate this task with their own time.
With patients checking their blood pressure at home under Florence’s prompting, Matt continued, they do not need to come into the practice to have a member of staff check it for them. “If they get a high result, they don’t need to come to us and ask about next steps – Florence automatically moves them onto the next stage of the seven-day check. That information comes back into a dashboard and staff can then directly see the blood pressure result that has come in. From there, we can look at the average and the trends.”
Jonathan showed how the diagnostic protocol was set up and how data is collected at 15:31. “As a clinician, you can see your patient cohort on the platform and you can see the communication between people,” he highlighted.
Administrative staff can onboard patients onto Florence, Matt said, and are supplied with the necessary blood pressure thresholds which allows them to remove patients from the platform as necessary. If a patient takes a seven-day check, administrative staff are then able to work out the average and communicate with the patient as to whether they can be removed or whether further clinical action is needed.
“A clinician only really needs to intervene with the remaining patients on the platform, with raised blood pressure,” he said. “We can then put them into dedicated hypertension clinics.”
Annual review protocol
“We also use Florence’s annual review protocol; we’ve worked with two practices with large numbers of patients needing a hypertension review, and we’ve been able to work with Generated Health and the GP teams to build a protocol that fits their needs. It works with the practices’ current protocol for hypertension management. It’s been brilliant because you can personalise it and make sure it suits your patient cohorts and your practice.”
A cohort is taken each month of the total practice population, with around 100 patients uploaded in bulk to Florence each time. Jonathan demonstrated how this works at 18:16.
“Those patients will be contacted by Flo, Flo will check whether they have a BP monitor at home. If they don’t, it will encourage them to see if they can access one. If they can’t, Flo flags the patient through the dashboard back to staff so that we can direct the patient to another way of getting their blood pressure taken,” Matt said.
“Flo checks if they can use the monitor and prompts them to get their bloods taken – there are links in the platform telling people how to book a blood test. Then it moves them into an annual review; we get the results back, Florence checks the patient’s BMI, their smoking status and so on. All that information that would normally need to be collected through a letter or an in-person review is done through Florence.”
A particular benefit, Matt highlighted, is receiving notifications into the system as they happen. “If we send a letter out to somebody and we don’t hear anything for two months, we don’t know why patient hasn’t engaged with us – it might be because they haven’t got a BP monitor, for example. With Florence, we can see the problem in real-time.”
Jonathan picked up on this: “We’ve all learned from COVID and the vaccination programme – how do we reach people who are not engaging? There are so many different reasons. With Florence you can start to gather information about those reasons, and you can see the population that you need to identify.”
As with the diagnostic protocol, administrative staff can then handle the patient cohorts and results on the platform. “If they feel the clinician needs to see the patient they can leave them on the system and then the clinicians can pick those cases up,” Matt said.
Jonathan noted how the annual review then cycles around, automatically following the patient up and checking up on them each year. “Once you’ve got people on board the Florence protocols, you already have a good efficiency in place for next year.”
“We’re learning from Florence all the time,” Matt agreed. “We’re gaining confidence and thinking about ways to develop protocols to help us further.”
In terms of the bulk upload, Jonathan noted that Matt and his team worked with Generated Health to try and get this system as smooth as possible.
“A manual upload would involve taking all the patient’s details from SystmOne and copying it across to Florence which probably takes a couple of minutes per patient – obviously you have to be careful when you’re taking information across that you actually keep everything correct,” Matt said. “With the bulk option, you can upload a CSV file of your patients with all that information, so that they are automatically on the Florence system. Once the patient is accepted and signed up, the protocol will start the algorithm automatically. There’s also less risk of making a manual error as well, because you’re not entering each patient onto the system individually and risking human error.”
Matt explained that his team have also been working with Generated Health on a straightforward way to do this. “Using recall or read codes, we are able to pull our list of patients out, put it in the order that we need. It’s really simple. Then that CSV file goes into Florence, choose the algorithm you want, and upload. Now I’d say we’ve got it down to 10 minutes to upload the whole cohort – you can probably do it in five once you’ve identified the cohort that you need.”
This protocol, Jonathan explained, focuses on trying to get patients to the maximum tolerated treatment with clinical governance.
Matt noted that practices can vary in how hypertension is treated in the early stages, so his team have looked at simplifying and standardising the process.
“Florence gives us the perfect opportunity to do this – we’ve built a titration protocol into the platform,” Matt explained.
The patient is given two prescriptions for medications depending on their personal health and condition. They are advised by the clinical team on which prescription to take and signed up to Florence’s titration protocol.
“Florence will remind them for the first two weeks to take the medication that we’ve indicated, naming it to be sure,” Matt said. “For the next two weeks, it gives them the option of continuing to receive daily reminders if they want to. This ongoing monitoring allows us to see any adverse effects that might develop, or any adherence issues.”
At four weeks, the patient is prompted to do a one-off blood pressure test. “If it’s within range, they’re asked to do a seven-day check,” Matt continued. “If they are above the target, which we expect with this cohort, then Florence will automatically prompt them to take the second medication. They will go through the same process again with another check four weeks later.”
It provides reassurance for staff, Matt said, around appropriate titration to medication for patients with high blood pressure. “With Florence, if I’ve got a patient on my dashboard, I know I’m going to see that patient,” he said. “I’m going to follow up with them. It’s reassuring for patients too – if they’ve got reminders, they know what they’re supposed to be doing.”
Jonathan then took questions from the audience, available to view below from 30:30.
Many thanks to Jonathan and Matthew for sharing their time and thoughts with us.