Digitally Transforming Primary Care – Making it Happen at Scale Conference

Digitally Transforming Primary Care –
Making it Happen at Scale
19th June 2019
For NHS leaders - Commissioning, workforce development,
digital delivery; practising GPs, general practice nurses,
practice managers; everyone involved in delivery of primary
care and evolving Primary Care Networks

Digitally Transforming Primary Care – Making it Happen
at Scale
19th June 2019
Introduction and welcome
Dr Ruth Chambers OBE
Clinical lead for technology enabled care
services, digital workstream, Staffordshire STP

at Scale
Digital transformation as the future of the NHS
Henrietta Mbeah-Bankas
Digital Literacy Lead and NHS Clinical Entrepreneur
Dr Roni Zeiger
Head of Health Strategy, Facebook

Improving Digital Literacy in NHS Staff
Henrietta Mbeah-Bankas
Digital Literacy Lead and NHS Clinical Entrepreneur

Health Education England definition
“Digital literacies are those capabilities
that fit someone for living, working,
learning, participating and thriving in a
digital society.”
What is digital literacy?
@NHS_HealthEdEng

What is driving the agenda?
• Five Year Forward View (2014)
• Personalised Health and Care 2020 (2014)
• Wachter Review (2016)
• General Practice Forward View (2016)
• Every Nurse an eNurse (2017)
• General Practice Ten Point Action Plan (2017)
• Topol Review (2018)
• NHS Long Term Plan (2019)
• Interim NHS People Plan (2019)
• A digital Framework for Allied Health Professionals (2019)
@NHS_HealthEdEng

The type of change
@NHS_HealthEdEng

• Patients
• Pace of technological change
• New technologies
• Confidence and competence
• Retention and recruitment
• Efficiency and effectiveness
Why is digital literacy important?
@NHS_HealthEdEng

The digital capabilities framework

www.england.nhs.uk
Adaptability = digital readiness
Digital ready
Digitally willing
Individual attitudes
Organisational
“drivers”
Digitally able
Skills
Technology
Everyone
Organisation leaders
Everyone
Informaticians
@NHS_HealthEdEng

www.england.nhs.uk
BDRW on a slide
WIDENING DIGITAL
PARTICIPATION DIGITAL LITERACY
CEO
Nurse
Dr
AHP
Social
Worker
Patient/
Citizen
CHANGE
• Culture
• Assurance
• Future focus
CHANGE
• Empowerment
• Staff development
• Changing attitudes
CHANGE
• Staff development
• User needs
• Service
• Sharing and listening
Non-
clinician
Local health/ care
organisation(s)
CIO
Informatician
@NHS_HealthEdEng

• Digital capabilities framework
• Discovery – diagnostic tools
• Existing resources
• Nursing and informatician consultations
• Individual digital readiness to learn (Towards
Maturity)
• Pilot work e.g. social care, dentistry, digital
championship
What are we doing?
@NHS_HealthEdEng

How do we upskill our workforce?
@NHS_HealthEdEng
How do we convince people that digital is important to
ALL OF US and the people we care for?
How can we teach and develop people at scale?
How do we reach those who have little to no digital
capabilities – how do we avoid excluding them?
What works
best ?
How do you upskill
over 3million people?

What can you
do?
What are you
already
doing?
@NHS_HealthEdEng

@NHS_HealthEdEng
Thank you
To learn more, go to the
HEE website and search
‘digital literacy’

@NHS_HealthEdEng
Any Questions?
Henrietta.mbeah-bankas@hee.nhs.uk
@mbeah_bankas

www.england.nhs.uk
A peek into the
General Practice
Nursing digital
future
Jason Westwood - General Practice Nursing
Programme Manager, NHS England

www.england.nhs.uk 20
Our Future Nurse

• 1. Empowering people
- NHS & other support LTC Apps
- Mobile monitoring
- Access to care record
• 2. Supporting health and care professionals
- Optimised clinical processes
- Addressing the operational issues for Community
& Primary Care Teams
- Digital leadership

• 3. Supporting clinical care
- Digital GP
- Greater use of ‘virtual’ contact
- Improved pathways
• 4. Improving population health
- Population health managements solutions to
ICS/PCN
• 5. Improving clinical efficiency and safety
- Technology assisted diagnostics
- Clinically capable workforce
- Safe interoperability
- Use of secure ‘Open Source’ tech

GPN 10PP Digital Objectives
Formation of digital ambassadors in General Practice Nursing
Facilitate supervision through a digital platform
‘Single Point of Access’ to GPN digital resources

GPN Digital
Ambassadors
Our aims are for individual practice nurse
participants to use at least two modes of
technology enabled care service in their practice
(and have at least 20% of patients signed up to GP
Online) selected from:
• Use of Closed Facebook and/or WhatsApp and/or other trusted
apps to support patients with long term conditions
• Encourage patients’ intelligent use of GP Online (e.g. those with
long term conditions accessing their medical records to enhance
their understanding of their health condition and
treatments/tests)
• Reduction in proportion of face to face consultations e.g.
substitution by video consultation / use of clinician/patient texts
• Increase in access to self-care information and then shared
management of long term condition
• Consistent professional approach to TECS by general practice
(and other) nurses and clinicians across the health economy;
and enthusiastic clinical engagement in digital delivery of
general practice care.

Digital Supervision – Background
• Clinical & other types of supervision varies across
England
• Some CCGs/STPs support local clinical supervision
• No consistent model of supervision used across
England
• Revalidation support will increase over coming years

Digital Supervision – The ask…
• Simple access from same portal
supporting all transformation
• Group and 1:1 capability
• Flexible access over multiple
platforms
• Scheduling
• Platform encompasses
consistent model

Work stream
Platform Model
Digital
Supervision
Supported Supervisors
Consistent Approach
Assured Delivery
Cost
effective
Scalable &
Modular

Phase Two - Aim
• Integrate into the NHS
Futures platform
• Gain the capability to record
group and 1:1 session
headlines/actions on
participants records for audit
retrieval or use in nurse
revalidation.
• Embed and support the
formulated national model of
supervision for GPN

GPN Single Point
• Home for all assured programme resources
• News and discussion
• National project areas
• Regional specific hubs
• Events and opportunities
• Platform integration
Request access via england.gpnsinglep@nhs.net

www.england.nhs.uk
Jason Westwood
General Practice Nursing Programme Manager
Nursing Directorate, Nursing and Midwifery Team
07714 773334 - jason.westwood@nhs.net
or follow me on Twitter @NHSjwestwood

NHSX
Digital Nurse Network
19 June 2019
Ann Gregory RN and Helen Crowther RN,
Clinical Nurse Advisors to the Primary Care Digital Transformation Team
Twitter: @AnnGregoryRN | @nursehelenc | @JennieSmiith

The Digital Nurse Network is an online
community supporting nursing teams
within general practice and other care
settings to increase their awareness of
digital services and national programmes.
Why? To reduce the pressure on primary
care, improve medical outcomes and
provide better patient and staff experience.
In support of the Long term Plan and new
GP contract - we want to help build a
digital ready workforce, sustainable for
the future.
Mission statement:
‘Together as a collective, our voice will be heard so
much louder than as individuals. Together we can
shape digital nursing into something that works for
everyone.’
Webinar one feedback from member:
“I'm a lone practice nurse and it's brilliant
being able to network with everyone.”

What is the Digital Nurse Network?
Social MediaOnline platform
Online community
Digital projects
Events
Webinars

What’s in it for you?
Digital Nurse
Network
Training
Up to date
information
Upskilling
Sharing
Collaboration
Support
Innovation
Being part of
something
bigger
Briefings

How do you get involved?
Tell another
nurse
Join our online
platform
What else
can
members
do?
Follow us on
Twitter
Join our
mailing list
Tell us about
your digital
project
Invite us to
your events
How can
you get
involved?

Contact
digitalnursenetwork@nhsx.nhs.uk
@AnnGregoryRN
@nursehelenc
@JennieSmiith
#DigitalNurseNetwork
www.source4networks.org.uk
Sign up and search:

Technology enabled care
services driven by our
digital general practice
nurse champions
Rachel Hatfield, National Programme Manager
Ann Hughes, Expert Digital Nurse
Kellie Johnson, Clinical Quality Improvement Manager

Developing
confidence,
capability and
capacity for
delivery of
technology
enabled care
rachel.hatfield1@nhs.net | ann.hughes@nhs.net | kellie.johnson@stoke.nhs.uk
The national action learning programme creates digital general practice
nurse champions who can showcase what is possible through technology
enabled care services (TECS)
The programme was funded by NHS England underpinning the General
Practice Nurse Ten Point Plan Action 6 (NHS England, 2017)
The general practice nurses participated in a series of action learning sets
in order to adopt and embed technology enabled care services (TECS)
within their practices, and develop as digital nurse champions
It has provided proof-of-concept that a ‘ground-up’ approach to upskill and
empower clinicians at the frontline is key to embedding the use of
technology enabled care services (TECS)
Vast numbers of practitioners/patients are being left behind as technology
is being deployed in an ad hoc way, with its real purpose never being
realised
Adoption and dissemination of the use of TECS by general practice nurses
embeds a range of TECS as part of usual service delivery -focused on health
conditions and adverse lifestyle habits

National rollout of the GPN action learning set
programme
The successful national programme has digitally
upskilled 160 general practice nurses with the
ability to focus adoption of TECS on areas of clinical
need - a key element for the next stage in the
digital transformation of healthcare.
Staffordshire – 40 nurses
 London Southwark - 20 nurses
 London Euston - 10 nurses
 Dorset - 20 nurses
 Birmingham and Solihull - 20 nurses
 Lancashire - 20 nurses
 Black Country - 10 nurses
 Merseyside -10 nurses
 Sunderland - 10 nursesrachel.hatfield1@nhs.net | ann.hughes@nhs.net |
kellie.johnson@stoke.nhs.uk

Participant Resources
Each participant attended two action learning sessions
(eight weeks apart).
They were introduced to the available modes of TECS and
received individual support to implement their two
chosen modes in practice.
They participant received the necessary delivery kit and a
suite of educational resources for their learning through
the programme including:
 A tablet with the key apps loaded (Facebook,
WhatsApp, Manage Your Health app, video-
consultation), with data prepaid for 12 months to
ensure internet connectivity wherever the site of care.
 A digital handbook
 A suite of learning documents
rachel.hatfield1@nhs.net | ann.hughes@nhs.net |

Video case study - Linda Drake, GPN, London
• https://vimeo.com/341566105

Modes of
TECS shared
at the ALS
sessions
FACEBOOK – PUBLIC
PAGES AND CLOSED
GROUPS
ANIMATIONS APPS
VIDEO-CONSULTATION TELEHEALTH WHATSAPP GROUPS

Video-consultations
• https://vimeo.com/342005785

TECS - accessible
to all...
- all modes of
technology
- all health care
settings
- all clinicians and
patients
rachel.hatfield1@nhs.net | ann.hughes@nhs.net | kellie.johnson@stoke.nhs.uk 48

Animations – health promotion messages
https://vimeo.com/313326545

The programme has delivered many benefits for
the GPNs and their practice teams including:
Reducing avoidable face-
to-face interactions (using
video consultation /
simple tele-health / health
messaging)
Increasing patient shared
care and self-
management of long-term
conditions
Patients and family more
engaged and reassured
through the access of safe
and trusted information
Improved patient access
to reliable sources of safe
and accurate information
about their long-term
conditions (LTCs)
Patients enabled to
manage their symptoms
at home and recognise
early deteriorating
symptoms
Sign posting to
educational and
monitoring resources
which can be accessed
when needed
Avoidance of unnecessary
treatment through
improved compliance
Efficiencies through
remote monitoring for
both patients and
clinicians
Improved information
sharing

Patient
perspective
(observed by
general
practice
nurses)
Increased knowledge of their condition – resulting in increased
engagement and reassurance on how to manage their condition
Shared care – more involved in the management of their
condition
Patients confident to manage their symptoms at home –
knowing when they need to access further support
Improved access to monitoring and treatment – access to
information at their fingertips
Patients felt empowered to take charge of their health
Access to trusted and safe information about their condition
when they need it
Patients able to cascade information to family and friends

Nurses’
perspectives
Technology is a major factor impacting nursing practice and clinicians are at the forefront as
leaders of technology enabled care initiatives
Being technologically adept can improve healthcare career opportunities
TECS was well received by the whole practice team as it improved patient experience and long
term health outcomes
TECS allowed for better use of resources – particularly clinician time as it allowed for a more
streamlined and efficient management process.
TECS helped empower patients and educate them about their condition. Improving self-
management
TECS added another tool to add to the clinician ‘toolbelt’
It increased engagement as provided another way to communicate
Felt more shared care between clinician and patient and opened a two way conversation
Provided a constant learning opportunity for clinicians
Allowed increased knowledge of specific conditions

Choice or movement?
• NHS Long Term Plan (2019) - Digital technology will provide convenient ways for patients to access advice
and care
• Royal College of Nursing (2016) – Every nurse an e-nurse by 2020
• Leading Change Adding Value (2016) - We will champion the use of technology and informatics to improve
practice, address unwarranted variations and enhance outcomes
• The Queen’s Nursing Institute (2013) – Smart New World
The cultural change required to move forward technology as a key aspect of our community services
is our biggest challenge. The technology in many ways is the easy bit, but as many a writer would say,
the key to culture change rests within our own behaviour.
Technology will never replace the expert nurse; both are needed to deliver high quality care to
patients. Neither will the nurse, however expert, be able to substitute entirely for the use of
technology in modern health care. That would be as unfair as denying a patient modern medicines.

Practice-wide approach
• Shared vision and values
• Promotes a wider sense of ownership/exchange ideas
• Teamwork skills/blends strengths
• Effective/efficient collaboration (share the load!)
• Consistent language
• Improved patient outcomes
• Increased patient satisfaction
• Increased staff satisfaction

NEXT STEPS…..WHERE TO ACCESS RESOURCES
WWW.CLINITECS.UK
PROTOCOLS
HOW TO GUIDES
GOVERNANCE / PRIVACY IMPACT ASSESMENTS
MARKETING / POSTERS
VIDEOS / ANIMATIONS

http://www.clinitecs.uk

Digitally Transforming Primary
Care – Making it Happen at Scale
PANEL / AUDIENCE QUESTIONS

Digitally Transforming Primary Care – Making it Happen at Scale
19th June 2019
Action learning examples - how digital champions
implemented technology enabled care:
Using Facebook – Kate Lilley
Using WhatsApp / digital surveys – Jenny Mather
Facebook closed groups – Nick Hartshorne-Evans
Using different modes of TECS – Louise Brown

Kate Lilley
Facebook Practice Page

Jenny Mather
Using WhatsApp and Survey
Monkey

Nick Hartshorne-Evans
Founder and CEO of the
Pumping Marvellous Foundation
The UK’s patient led HF Charity

The Pumping Marvellous Perspective
Facebook Closed Groups in Health
The Power of Community

Why do we do
what we do?
We are people with heart failure
who wish to make the lives of
people living with heart failure
better
We deliver superior patient
insights holding decision
makers accountable

How do we do what we do?
We work with people
with Heart Failure to understand
their needs to develop solutions?
We work with all stakeholders
delivering valuable patient
insights into the system?

What we do / Who do we partner with ?
• Patient Experts with NICE technology appraisals – Pharma and MEDTECH
• Patient representative on the NICE Chronic Heart Failure Guidelines 2018
• Mentor for NHS England Clinical Entrepreneur Programme
• Greater Manchester Health and Social Care Partnership
• Greater Manchester and East Cheshire Cardiac Network Community Heart Failure Project
group lead
• Pan London Heart Failure steering group member
• Member of the Scottish Heart Failure Hub
• Observer – National Advisory Committee for Heart Disease - Scotland
• Patient experts for several high profile NIHR funded research studies and programmes
• Founder of iHHub Global - President 2014-2016
• Board Advisor to the Canadian HeartLife Foundation
• Work with European Society of Cardiology’s Heart Failure Association, British Society for
Heart Failure and the British Society of Echocardiography amongst others as their patient
experts
• We help people live better with heart failure
• We manage the largest non-profit social media platforms for people living with heart failure
• We generate huge social media conversations across multi platforms
• We manage a unique platform for 500+ HF nurses in the UK, Europe, Globally
• We supply over 200 Heart Failure Clinical Teams with patient information – Just under
100,000 pieces of patient information supplied in 2018
• We work with the British Society of Heart Failure, leading Cardiologists and Heart Failure
Specialist Nurses to help shape policy in heart failure through NHS England and NICE
• We developed and managed a globally unique platform that allows patients to understand
what services are available through an online mapping platform
• Our platform JustHeartFailure.org allows people to find their local heart failure nursing team
• We are creators and owners of the UK Heart Failure Nurse Audit

Where it all started - The Pumping Marvellous Foundation
Nick was diagnosed with
HF in 2010
His experiences shaped
ideas
There was a need for
championing patients and
their families needs
It became obvious the
system needed patient
insights
Somebody needed to do it

We are “Uberizers” who make great
looking jigsaws

Our aim
To help people with
heart failure live their
lives better
As this is what
patients want
Aspire to be the very
best patient group we
can be

We see heart failure through the patient lens

We facilitate powerful neural patient communities
• Patients, carers and families use our online communities for many reasons
• Support
• Knowledge
• Community
• Peer to peer decision making
• How they interact with the system

Deliver patient insights influencing the system
• Always coming from the patient need
• The Department of Health including the NHS and Public
Health England along with NICE have never had it so good
• Patient insights on tap
• Shaping policy

The Pumping Marvellous Foundation Closed Group
Helps people live better with heart failure
Delivers insights to shape quality improvement
Drives ”Long Term Plan” initiative around self-management

“Generation Now – The patient revolution” NHE the Economist
“This is the industrial
revolution
in minutes not years”

Challenging problem
Patients tells us that the Heart Failure Specialist is the
most important member of their team
Heart Failure Specialist Nurses are under threat, vulnerable
to losing their specialism
They only meet one another maybe once or twice a year
Generally they work in isolation, not connected with each other
They need an advocate
This in the medium term must be the patient

Solution?
Could we replicate our success with the patient community?
Could we gain the trust of the Heart Failure Nurse Community?
Could we get them to see the value?
Could we get them to participate?
Could we start to develop tangible benefits to patients?
Could we overcome the hesitation around social media in health?

Tangible Benefits
It is the largest Heart Failure Nurse Community Globally
It connects 507 Heart Failure Specialist Nurses
Countries represented UK, Netherlands, Germany,
Australia, Canada, Sweden
Spawns opportunities
Increases communication and learning
Develops cross learning
Benefits patients

Tangible Benefits
It is the largest Heart Failure Nurse Community Globally
It connects 507 Heart Failure Specialist Nurses
Countries represented UK, Netherlands, Germany,
Australia, Canada, Sweden
Spawns opportunities
Increases communication and learning
Develops cross learning
Benefits patients
This has to be good for patients

GPN. RN (CHILD) DIPHE
ROYAL ARSENAL MEDICAL CENTRE, WOOLWICH, SE LONDON

ASTHMA & COPD DIABETES
Aim to Target patients who weren’t
engaging,
E.g. not attending annual reviews
or have poor disease control.
Use technology to encourage patients
to take ownership of their diseases.

19th June 2019
QUESTIONS….?

Digitally Transforming Primary Care –
Making it Happen at Scale
19th June 2019
For NHS leaders - Commissioning, workforce development, digital
delivery; practising GPs, general practice nurses, practice managers;
everyone involved in delivery of primary care and evolving Primary
Care Networks

at Scale
19th June 2019
Andy Hadley
Primary Care Digital Programme Lead,
Staffordshire CCGs

Primary Care Digital Transformation @ NHSX 94
Primary Care Digital Transformation
Dr Clive Prince
Clinical Advisor, Primary Care Digital
Transformation programmes, NHSX
RCGP Person Centred Care Network of
Champions
GP IT Futures
GP IT Operating
Framework
GP Online
Services
Clinical
Networks
GP online services
Patient empowerment as a result of accessing their
records online
June 2019

Advice to
check symptoms
See what’s in
their record
Order meds
Access to the right
medical help
What many patients do…
Self
care
A&E
Fast triage to the most
appropriate
type of care
Pharmacy
GP
practice
Book an
appointment

Vision for patient access to records

?
Where are we now and
where are we going?

Empowering patients
“My blood pressure is
recorded there”
Two years ago I was at a stage in my understanding … that
was so limited it placed the entire weight of responsibility for
my care on the doctors treating my condition. I was a
passenger, along for the ride.
Access to my medical data … has empowered me as a
patient and given me a platform for the sort of communication
with my healthcare professional that Person Centred Care
appears to seek to achieve.
In short “I am no longer a passenger, I am now very much
part of the management team for the effective treatment of
my condition.”
O.C. Manchester, October 2017

Why do patients want
digital?

Comments from patients
“I can receive
much quicker,
more efficient
care”.
“It's really helpful to
be able to remind
yourself what was
said to you by your
GP”.
“Easier for me to
keep track of my
results.
“I'm impressed
how quickly my
blood tests are
on there”.
“It is good to have
the choice”.

Results from the 2016 Patient Online survey

Case study: patient access to test results

Structured personalised care in type 2
diabetes reduces complications
474 GPs recruited 1381 patients
BMJ 20 April 2013

Evidence of the patient appetite for digital
11% of people have access to a
health wearable such as a fitness
tracker
Over 15 million registered for online
services in their GP practice and each
month
• 1m appointments booked online
• 3m prescriptions renewed online
• 840k records accessed online
Healthwatch Enfield report
Asked about options to reduce burden
on their GP
• two in three said being able to
email their GP for medical advice
• almost two in three said symptom
checker from a trusted NHS website
or app
• three in five said having a GP
appointment via video calling

Are people ready to go digital?
• Over 90% people in England have internet
access
• Though there is still an age divide: 60% of
over 65s use the internet
• 50% of all adults access healthcare
information online
• 1 in 20 of all Google searches are health
related
77% of Europeans use their mobile
phone to manage their finances
• 75% of people (over 15 years) own
a smart phone
• 66% of visits to NHS.UK are on
smartphones
For banking customers who are online:
21% use mobile banking
27% use online
40% use both
12% use neither
• 43% of people use the internet to find out
about conditions, treatments, managing
conditions and preparing for medical
appointment
• 60% who use the internet to check a
condition don’t go on to use a frontline
service

GMS Contract 2019-2024
Investment and evolution:
A five-year framework for GP contract reform to
implement The NHS Long Term Plan
31 January 2019

GP contract – where it fits into current activity
5.10 NHS England and GPC England have agreed eight specific improvements, backed
by agreed contract changes, in areas where it is realistic to make early progress, given
available functionality
Reference Description Timescales
Programme name
Related programme
5.10 (i) all patients will have the right to online and video consultation By Apr-21 Online consultations
5.10 (ii)
all patients will have online access to their full record, including the
ability to add their own
From Apr-20 GP online services
new registrants having full online access to prospective data From Apr-19 GP online services
5.10 (iii)
offering and promoting electronic ordering of repeat prescriptions
and using electronic repeat dispensing
From Apr-19 GP online services
5.10 (iv) at least 25% of appointments are available for online booking By Jul-19 GP online services
5.10 (v)
all practices will need to have an up-to-date and informative online
presence
By Apr-20
Enhancing practice
websites
5.10 (vi) patients access online to correspondence, By Apr-20 GP online services

But it’s not just about the digital…
“The wiring of healthcare has proven to be the Mother of
All Adaptive Problems. Yet we’ve mistakenly treated it as a
technical problem: simply buy the computer system,
went the conventional wisdom, take off the shrink-wrap,
and flip the switch.”
Robert Wachter
Whole systems approach required to enable technology
1. Activating our patients
2. Adapting our workforce
3. New operational approaches to caseload management

Primary Care ‘Universal’ Digital Offer
We will empower people to
participate in their health and
care using digital services that
meet their needs, target
prevention and offer a
personalised experience how,
when and where they choose

@nachic @staffsbiomech n.chockalingam@staffs.ac.uk
Digital healthcare for the foot
to help prevent diabetes complications
nachiappan chockalingam

the brief
… “can you provide an overview of your work in the
area diabetic foot, the techniques and technologies
that you have developed. How can your work
influence technology enabled care at the primary care
level and the benefits for the practice and the
patient”

Scope and Boundaries
…“it is not about redesigning existing clinical
management procedures to deal with ulcers”
…but
…“to effectively prevent diabetic foot
ulceration (DFU) by helping people who have
not ulcerated before to remain ulcer free”

Total number of adults with diabetes (20-79 years)

ISDF Atlas 2017
Kerr et al. 2019. The cost of diabetic foot ulcers and amputations to the National
Health Service in England. Diabetic Medicine.
• diabetic foot care accounts for a substantial
proportion of healthcare expenditure in
England, more than the combined cost of
breast, prostate and lung cancers
• more than 90% of these costs are for ulcer
care
• if the NHS were to reduce the prevalence of
diabetic foot ulcers in England by one-third,
the gross annual saving would be more than
£250 million

• the most common causal pathway to the development of diabetic foot ulcers is the
accumulation of trauma, neuropathy, and deformity
• approximately 80% of ulcers involve some form of trauma1 and therefore are potentially
preventable
• the development of many ulcers is related to ill fitting footwear2, with footwear found to be a
factor in 42% diabetic amputations3
• it has been reported that providing footwear to all patients with diabetes at risk for ulceration
would be a cost effective and potentially cost saving measure4
1Reiber et al. (1999) Diabetes Care, 22(1), 157–162.
2Apelqvist et a. (1990) The Journal of Diabetic Complications, 4(1), 21–25.
3Reiber, G. E. (1994) Journal of Rehabilitation Research and Development, 31, 357–362.
4Ragnarson Tennvall, G., & Apelqvist, J. (2001). Diabetologia, 44(11), 2077–2087.

Impact
• 3.6m People have Diabetes
• 25% will develop a foot ulcer
• 7,370 amputations / year
Cost
• Ulcers: £3,221(Minor), £6,246 (Major)
• Amputations: £8,450 (Minor),
(Major)
• Total Cost to NHS: £837 million to
£962 million (=0.8% to 0.9% of NHS
budget for England)
Average CCG

• 85% of all amputations begin with a single foot ulcer
• once ulcerated, healing is slow and recurrence high
• custom orthoses can prevent 65%* of foot ulcers by reducing
peak plantar pressure by 15-21%
current custom orthoses are slow to produce, expensive and not
uniform…
Only 21% of high risk patients receive them
*Source: Costing Report: Implementing the NICE guideline on diabetic foot problems (NG19) , Aug’15

science
engineering and technology

• some research has examined the effectiveness of footwear in preventing
ulceration and the effectiveness of footwear interventions to prevent re-
ulceration
• results from cross sectional studies support the use of rocker sole footwear
and custom orthoses in plantar pressure reduction, however the effective of
these in ulceration prevention needs to be verified through longitudinal
studies
• …generic recommendations are not possible as the
optimal design will be patient specific

• ulcerating for the first time is a particularly important negative milestone
because it significantly increases the risk for ulcerating again
• 40% of people with healed ulcers re-ulcerate within a year and 60% re-
ulcerate within three years [1] increasing significantly the risk for
amputation and premature death
• primary DFU increases the 5-year risk of death by 250% while the 5-
year survival rate following a diabetes-related amputation is lower than
that of prostate cancer and of breast cancer in men and women
respectively[2,3]
1. Armstrong DG et al., Diabetic Foot Ulcers and Their Recurrence. N Engl J Med 2017;376:2367–75. doi:10.1056/NEJMra1615439.
2. Gary Sibbald RG & Ayello EA. The Reduction of Diabetic Foot Amputations Starts with Preventing Foot Ulcers. Adv Ski Wound Care 2018;31:389.
doi:10.1097/01.ASW.0000544473.65179.bf.
3. Walsh JW et al., Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med 2016;33:1493–8.
doi:10.1111/dme.13054.

Scanning and 3 D printing

Bespoke, 3D Printed
• Inputs: 3D foot scan & patient
weight
• Captures foot shape and load
zones
• Auto-design patient specific orthotic
• Variable density zones, form fitting
• Patient-specific pressure reduction
(~21%)
• Manufactured using rubber material
in 1-2hrs
10x lower cost
Durable
Insoles maintain functional
performance during lifetime.
Automated system
Can be used by non-specialist:
frees up podiatrist time for more
complex cases.
Better compliance
Fit into standard footwear.
Better airflow to foot
Low cost – multiple pairs

• pilot studies indicate that the imprints insoles can offer
significantly higher pressure reduction compared to a standard
care insole with the same thickness that is routinely used within
NHS
• material testing suggested that the printed insoles are more
durable than traditional orthoses made from foams and may
require less frequent replacement
• health economic analysis showed that the cost of providing
imprints insoles, including clinicians’ time, is 51% lower than
current practice

• overall ulcer incidence of 5.8 and 6.0% have been reported in
selected populations of people with diabetes in the U.S. and an
incidence of 2.1 and 2.2% have been reported from less selected
populations in Europe
• although there is no clear evidence on whether this incidence is
changing, some reports might show a short-term fall resulting
from the impact of structured screening
• without major improvements in ulcer prevention, one can predict
that this fall will be followed by a rise in the number of ulcers that
will increase in conjunction with the increase of type 2 diabetes

“technology enabled care
at the primary care level
will improve the
effectiveness and costs
effectiveness of care and
will provide benefit the
practice and the patient”

@VHShed
Transforming
Patient Information
From novel to
normal
Luke Bracegirdle (Director)
luke@vhshed.com
linkedin.com/in/lukebracegirdle

@VHShed
Patient Information
What is normal?

@VHShed
Is digital novel or normal?
In the UK….
 78% personally use a smartphone
(33% in 2015, 17% in 2008)
 76% of smartphone owners use it to go online
 58% have a tablet (2% in 2008)
 28% have a desktop PC (69% in 2008)
 Arrival of new devices (smart speakers,
wearable tech, watches and VR headsets
Source: Ofcom 2018 Communications Marketing Report
https://www.ofcom.org.uk/__data/assets/pdf_file/0022/1
17256/CMR-2018-narrative-report.pdf

@VHShed
Is digital normal...just for young people?

@VHShed
About
Virtual Health
SHED
Prof. Stephen
Chapman
Luke
Bracegirdle
 Simulate clinical scenarios for
workforce training at scale
 Health information for digital platforms
 Education for clinical professionals via
distance learning and accreditation
 Digital innovation designed to extend the
reach of a project
Two company directors with experience of
 NHS
 Academia & distance learning
 Pharmaceutical Industry
 Regulatory bodies
 Software development industry

@VHShed
What we do…
 Identify the users & their
digital environment
 Produce clinical & digital
content to reinforce a
health message
 Design the resource with
public and professional
review
 Deploy the digital
resource within the
“reach” of the intended
users

@VHShed
Design with the person:
Solving the App Store
One patient group reported difficulties installing native “apps”
and navigating the App store
A benefit of a native app is it can operate without an internet
connection and have more features
Use a Google framework to develop an ‘app’ that is installed by
clicking a hyperlink. It work likes an app without the need for
an internet connection after the initial visit

@VHShed
Designing with
analytics
 “It will reinforce the written
management plans … and be
accessible at all times on their
phone or tablet, unlike the
Management plans which may be
put away into a drawer at home”
 A health app with a high (> 70%)
return/loyalty rate
 Each users accessed average of 32
app resources each (14,843 pages)
 Small user base
App analytics gave the project
team the insights to respond

@VHShed
Designing with the
user & healthcare
team
 A patient resource is triggered using
technology already in a home or
workplace
 Content is linked to the time/place to
reinforce a health message
(a clinic not always the best place to
learn)
Digital Inclusion Programme
Funded by NHSE across Staffordshire to
 Design an app for a clinician to use in a
consultation to explain Atrial Fibrillation
 Use a home assistant (e.g. Echo devices)
to relay validated health messages

@VHShed
Person-centred
Design
How can clinicians
explain
Atrial Fibrillation?
….with the patient!

@VHShed
Designing with
Governance
A changing landscape for developing
digital resources for health
 MHRA guidance
 Use the latest ”open” software
frameworks to promote
interoperability

@VHShed
Luke Bracegirdle (Director)
luke@vhshed.com
linkedin.com/in/lukebracegirdle
Thankyou

147
Phil O’Connell
Simple Shared Healthcare Social Enterprise
Clinical Messaging Consultant to the US VHA
The NHS Inspirational Leader of the Year 2013 (WM)
The NHS Innovator of the Year 2012
MBCS CITP
www.simple.uk.net

Spending money on tech?
Buying Snake Oil?
Regression to the mean?

149
In the beginning
a robust education !!!!!

150
In the beginning
helping clinicians to innovate
2009
Simply the simplest

151
Totally Unique
”An enabler, not a solution”

153
Cottrell E, Chambers R, O’Connell P (2012) Using simple telehealth in primary care to
reduce blood pressure: a service evaluation. BMJ Open 2:e001391.
• education
• advice
• prompts
• questions
• feedback

Journey highlights
• 2012 “The NHS Innovator of the Year”;
• 2012 NICE’s shared learning database
• 2014 United States Dept of Veterans Affairs (VA) Annie
• 2015 The Health Foundation “Power of People”
• 2016 Australia; next generation of system ”Nellie”
• 2016 Nuffield Trust “The digital patient: transforming primary care?”
• 2017 NHS Sustainability Awards winner; Heart Failure.
• 2017 RCGP “introduction to TECS” course;
• 2018 The King’s Fund 1 of 8 “Adoption and spread of innovation in the NHS”
• 2018 Innovation Unit/The Health Foundation 1 of 10 “AGAINST THE ODDS”
• 2019 Scottish Government announce Flo as national service

Journals
• 2012: BMJ Open - 2012;2:e001391 Elizabeth Cottrell, Ruth Chambers, Phil O'Connell; Using simple telehealth in
primary care to reduce blood pressure: a service evaluation
• 2012: BMJ Open 2012;2:e001392 Elizabeth Cottrell, Kate McMillan, Ruth Chambers ; A cross-sectional survey
and service evaluation of simple telehealth in primary care: what do patients think?
• 2014: Dove Press - 10.2147/NRR.S72791 Audrey Cund, Jayne L Birch-Jones, Martin Kay, Patricia Connolly; Self-
management: keeping it simple with “Flo”
• 2015: BMJ Open - 2015;5:e007270 Elizabeth Cottrell, Tracey Cox, Phil O'Connell, Ruth Chambers; Patient and
professional user experiences of simple telehealth for hypertension, medication reminders and smoking
cessation: a service evaluation
• 2015: Gastrointestinal Nursing - 10.12968/gasn.2014.12.Sup1 Mark Holmes, Sian Clark; TECHNOLOGY-ENABLED
CARE SERVICES: NOVEL METHOD OF MANAGING LIVER DISEASE
• 2015: BMC Family Practice 2015, 16:83 doi:10.1186/s12875-015-0301-2, Elizabeth Cottrell, Tracey Cox, Phil
O’Connell, Ruth Chambers; Implementation of simple telehealth to manage hypertension in general practice: a
service evaluation
• 2016: British Journal of Healthcare Management 10.12968/bjhc.2016.22.1.23 Lisa Taylor, Jane Birch-Jones;
Implementing a technology enabled care service
• 2016: (RCNi) Primary Health Care, 2016, 26(7):24-30 http://dx.doi.org/10.7748/phc.2016.e1137 Caroline Poole,
Janice Maslen, Lisa Joanne Taylor; Enabling Supported Self-Management of Wound Care in the Community
Setting to Increase Quality and Efficiency of Service Delivery" Primary Health Care
• 2016: Journal of Nursing & Healthcare, 2016 Vol. 1 Issue 2; Parijat De , Susan Irwin, Jagjit Kaur, Karen Moore; Use
of an Innovative Technology Enabled Care Service (Tecs) “Florence” To Empower Patients and Enhance
Adherence to Treatments in Diabetes

156
Respected Evaluation
"Flo has had a huge impact on people’s
lives, revolutionising the way patients
manage their own health”
"Flo has been formally evaluated, with
positive results”
"Florence is a low-cost, low-risk
innovation with a strong track record”
The King’s Fund
Adoption and spread of innovation in the NHS
Nuffield Trust
The digital patient: transforming primary
care?
The Health
Foundation
The Power of People

157
Community of Practice
evidence, studies, peer review, collaboration,
shared learning, evidence, studies, peer review,
collaboration, shared learning, evidence, studies, peer
review, evidence, shared learning, evidence, studies, peer
review, collaboration, shared learning, evidence, studies,
peer review, collaboration, shared learning, evidence,
studies, peer review, collaboration, shared learning,
evidence, studies, peer review, collaboration, shared
learning, evidence, studies, peer review, collaboration,
review, collaboration, shared learning, evidence, studies,
peer review, collaboration, shared learning, evidence,
studies, peer review, collaboration, shared learning,
evidence, studies, peer review, collaboration, shared
learning, evidence, studies, peer review, collaboration,
review, evidence, resources, evidence, studies, peer review,
review, evidence, shared learning,

158
Established uses - UKFocus

159
Upcoming uses - UK
Innovation Exemplar
Others

160
At scale integration
A national
service

Change in
systolic blood
pressure over
time

Supporting nurses to use
animations and social
media
Cameron Booth, Digital Advisor,
Redmoor
Stephanie Zakrzewski RGN. Queens
Nurse, NMP, Lancashire
Emma Rogers RGN, Birmingham

The challenge:
How can you
use creative
methods to
engage the
public on
health?
Creative Facebook posts – posters,
videos, cartoons
Closed long term condition groups –
valuable engagement
Promotion of events e.g. flu sign
ups, local walking groups,
community groups
Creation of patient story videos
Animations on a range of health
topics

The strategy
 Let nurses develop the creative content and
storyboard
 Bring nurses together from different cohorts
via Whatsapp to share ideas
 Help them promote their animations via
Facebook and GP practice screens

Emma Rogers and Stephanie Zak
• Why did you choose to to use social media
and animations?
• Why did you choose NHS Healthchecks as a
topic?
• How did you find working together remotely?
• What has been the reaction to your
animation?
• Have you any more planned?

NORTH MIDLANDS BREAST SCREENING
Service
GINA NEWMAN
HEALTH IMPROVEMENT PRACTITIONER

How and why we use Facebook
as a platform to communicate

We have identified that there is a misconception in the over 70’s being
entitled for Breast screening. This is highlighted in each engagement
post.
Positive peer to peer encouragement has resulted in hard to reach
ladies engaging as they can remain anonymous to a certain level.
A number of Health inclusion and seldom reach groups share our
information and videos. These include :-, Asylum Seeker &
Refugee’s, Vulnerable & multiple needs, LGBT, BAME, Learning
disabilities .
On updating specific screening information we are able to
encourage engagement and advice on correct pathways to the
service.

In 2016, the proportion of eligible women taking up routine
breast screening invitations fell to its lowest rate in a 10 year
period in the UK. With the largest decline in the prevalent cohort
(First timers). Uptake in the Incident cohort (Routine) declined
slightly.
(NHS Digital, 2018)
Breast Screening

The UK National Screening Committee set two targets for the
Breast screening service to achieve; 70% minimum standard
and 80% national target overall.
Selected GP practices were targeted with a digital approach.
All practices saw an increase in overall uptake and an increase
in prevalent attendance, therefore reversing the national 10yr
decline.

Women who have previously DNA’d their
appointment have contacted us via Facebook.
Through this communication their breast
screening appointments have been rebooked
and attended.
Positive outcomes from the use of
Facebook

Challenges of social media
• Extending our engagement reach to challenging diverse areas,
which have a low uptake for screening and do not engage with
the Breast Screening Facebook page.
• Health literacy levels
• Breaking down barriers

What to expect from breast screening
animation
https://vimeo.com/241078206
This animation of the breast screening pathway, is understandable to all health
literacy levels and is also culturally sensitive. It has currently been viewed over 30k
times.

www.facebook.com/NorthMidlandsBreastScreeningService

at Scale
19th June 2019
Dr Ruth Chambers OBE
Clinical lead for technology enabled care
services, digital workstream, Staffordshire
STP

Dr Matthew Hammerton
Topol Review Clinical Fellow
19th June 2019
m.hammerton@nhs.net

• Independent government report lead by
Dr Eric Topol
• 70+ experts in digital medicine, genomics, AI &
robotics, ethics, education, economics and
organisational development
• Aims: To consider how technological innovation is
likely to change roles and functions of clinical staff
over the next 20 years to deliver more effective,
personalised care. The implications for workforce
skills and selection, curricula and education.
The Topol Review

• Convergence of genomics, biosensors, EPRs, smartphone apps
superimposed on a digital infrastructure with AI to make sense
of the overwhelming amount of data
• Delivering personalised, predictive, preventative and
participatory healthcare in a far more rationale and efficient
way. Essential for tackling the pressing 21st century challenges.
• Within 20 years, at least 90% of all NHS jobs will require some
element of digital skills.
WHY prepare the workforce

WHAT are we preparing the workforce for: Top tech
Arrow heat map
represents the
perceived magnitude
of impact on current
models of care and,
by inference, on the
proportion of
workforce affected.
<20%
50%
80%
>=80%

• Patients: At the centre when accessing/implementing new technology,
empowering those who are willing while respecting patient choice and working
to reduce healthcare inequalities.
• Evidence: Use of robust clinical validation including frameworks to evaluate
technology implementation as well as widespread critical appraisal skills and a
knowledge sharing culture.
• The gift of time: Wherever possible, the adoption of new technologies should
enable staff to gain more time to care improving the patient-clinician
relationship and alleviating burnout.
HOW do we prepare the workforce: 3 principles

Capacity, Capability and Creating the right environment
• Capacity: Skills required to enable a modern, data rich and digitally
progressive health environment are much sort after. Need to attract best
technologists, informaticians and data scientists by making the NHS a
destination employer and building new and innovative mutually beneficial
relationships with industry to share and develop scarce resources.
• Technology skills audit to increase understanding of current position and
explore factors affecting recruitment and retention
• Use of apprenticeship levy to upskill existing NHS staff
HOW do we accelerate adoption

• Capability: The entire healthcare workforce should be offered the opportunity
to develop a broad scope of digital and specialist technology literacy centred
on the processes that they are trying to complete.
• This will require a culture of learning that nurtures a growth mindset and
motivates lifelong and collaborative learning

• Creating the right environment: Enabling a culture, with our leaders at the
forefront, where digitally-supported care is the norm for both users and
providers
• This requires:
• High-quality digital leaders (CCIOs, CIOs, CNIOs) as cultural enablers
• Changes in the professional and regulatory landscape with explicit
understanding of the governance implications
• Acknowledgement of importance of transformation skills

NHS Long Term Plan workforce implementation group convened experts to work
together on most important workforce challenges facing the NHS, addressing the
recommendations of the Topol Review
• Group chaired by Sir David Behan, Chair of HEE
• Mapping the review recommendations along with
other ALB technology requirements
• High level plan for 2019/2020 and interim report
of ‘People Plan’ (released 06/19)
Technology skills and enablement group

1. Establish the board level leadership development model and start to deliver
‘digital boot camps’ for leaders to build tech and data awareness.
2. Provide an accreditation/credentialing framework for digital leaders.
3. Develop a library of education, learning, knowledge and best practice
resources to support the current workforce (generic and specialist
technology).
4. Work to develop and integrate digital education and learning resources into
academic and professional curricula.
Group Priorities 2019/2020

5. Building on the Topol Review, carry out an audit to assess and plan for future
digital roles and skills.
6. Set out plans for an expanded NHS Digital Academy to develop digital
leadership capability.
7. Establish the Topol Programme for Digital Fellowships in Healthcare.
8. Develop flexible career pathways, particularly for ‘scarce’ roles, and establish
early pathway initiatives for the future digital talent.
9. Continue to roll out the education and training interventions available from the
HEE Genomics Education Programme.
Group Priorities 2019/2020

“It really will be transformative that
eventually… the patient will be truly at the
centre.”
Eric Topol, MD
Thank you

Our relationship with technology

Digitally Transforming Primary Care – Making it
Happen at Scale
19th June 2019
Combatting vaccine misinformation
online
Jason Hirsch, Health Integrity Lead,
Facebook

19th June 2019
CLOSE – THANK YOU FOR
ATTENDING

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