Leading change

A Clinical Nurse led the implementation of Technology Enabled Care Services (TECS) at Ashley Surgery, a rural practice in Shropshire. This digital approach to care has significantly improved patient accessibility and experience, outcomes and use of resources locally.

Where to look

The Long-Term Plan (2019) highlights that digital technology can support the NHS to deliver high quality specialist care more efficiently. Relatedly, the NHS Commissioning Assembly describes Technology Enabled Care Services (TECS) as the use of convenient, accessible and cost-effective telehealth, telecare, telemedicine, telecoaching and self-care in providing care for patients with long term conditions. These services can transform the way in which people can engage in and control their own healthcare, empowering them to manage their care in a way that is right for them. To support its use in practice, the TECS Resources for Commissioners have been developed by NHS Commissioners to help maximise the value of technology enabled care services for patients, carers, commissioners and the whole health economy. Literature and clinical evidence purports that the use of TECS improves health outcomes and supports patients to reverse adverse lifestyle habits and manage their own health journey.

Within General Practice, the General Practice Nurse Ten Point Plan (NHS England, 2017) describes “supporting nurses to lead change and add value through the understanding, identification and use of tools to address unwarranted variation, including developing digital nurse champions within general practice”.

The Clinical Nurse Lead at Ashley Surgery identified that the surgery was not standardised in their approach to utilising TECS to support patients at the practice and that this was leading to unwarranted variation in the way people accessed the services and resources, particularly those less able to attend the surgery or those with long term conditions whereby self-management can be improved with TECS.

What to change

Prior to the change, the Clinical Nurse Lead identified some restrictions in accessibility to services at the surgery exacerbated by the rural nature of the practice. For example, patients who were housebound were unable to access an electrocardiogram (ECG) to assess for atrial fibrillation (AF), asthma review uptake was a challenge and there was concern for the ageing population having increasing difficulty accessing the practice. Patients were also reporting difficulty in attending long-term condition (LTC) reviews due to the distance and time required for travel during their working day. The Specialist Nurse Practitioner and Clinical Nurse Lead identified an opportunity to bring services to patients across the rural patch via TECS which aimed to support improving outcomes for patients by increasing accessibility to services.

How to change

The Clinical Nurse Lead started the process by engaging with and discussing TECS with the nursing and wider practice team, seeking a shared agreement to use the digital services within the practice.

Following this, a pilot for virtual asthma consultations was rolled out using telehealth approaches by two members of the nursing team. A pre-implementation phase, where staff used a role play approach to asthma reviews, supported the nurses in reflecting on anticipated patient experience as well as supporting the clinicians to use the technology. To start the roll out, a patient was identified as being due an asthma review and staff recognised they would welcome a flexible TECS approach to work around their personal commitments. An asthma control test questionnaire was also sent to them and they were supported to download a smart phone application that can be used to manage an individual’s health, which would provide the basis for the development of a clinical management plan. A successful virtual consultation took place with an asthma patient during their lunch break and they was happy that they were not needing to take time away from work – early positive feedback on the change.

With ongoing success in the pilot, the Clinical Nurse Lead developed protocols for the use of virtual consultations within the Surgery with support from a digital communications agency specialising in the practical application of simple technology digital solutions for point of care delivery. This agency was already working with North Staffordshire Clinical Commissioning Group (CCG) on TECS projects. Leaflets to promote the service were also produced and distributed in the practice for patients, families and carers.

As part of the programme, there has been an observable shift in the whole nursing team now promoting and supporting people with LTCs to consider and use the digital application to support them to effectively manage their health during reviews, using tablets to provide an introduction and demonstration of its use. Virtual consultations for annual asthma reviews are discussed with suitable patients and TECS is now offered to all who meet the criteria according to the protocol.

The practice website and associated social media account are now used to increase awareness of the offer and how this can support wellbeing. The TECS programme has also been taken to the practice’s proactive Patient Participation Group who have contributed to the programme and support promoting any new changes by providing constructive feedback and challenge.

Adding value

Better outcomes – TECS is providing a service to people who may previously have found appointments or engagement more difficult. The nursing team can now provide a more flexible, personalised service where they see, treat and organise subsequent appropriate treatment for patients using technology promoting health and wellbeing. There is a sense that this is also reducing possible social isolation. The use of self-management plans on the digital application can support improving asthma control and adherence. Practice asthma review levels, although already meeting recommended national targets have now improved to >80%, which is above the Clinical Commissioning Groups average and national average rates. The percentage of patients with well controlled blood pressure is >87% which is again above the CCG and national average rates.

Better experience – The support to patients with LTCs has been enhanced through implementing TECS and associated apps for managing an individual’s health and self-management plans. People report being increasingly in control of their symptoms as well as care package and that they can seek advice and obtain answers to their questions at the touch of a button. There has been good engagement with TECS and positive feedback on the virtual consultations from those using it. Early findings suggest the additional, remote support is welcomed and the flexibility the approach offers is well received.

Better use of resources – Virtual consultations are reducing travel time to the surgery for those attending reviews as well as offering easier access to appointments for review. It is anticipated that this will have a positive impact on reducing rates of missed appointments. Use of the digital application for managing an individual’s health is resulting in a more effective, personalised nurse-led review appointment – and more sessions can be offered as a result. Patients of working age require less time out of work following the implementation of virtual consultations which has been a further positive outcome of the programme.

Challenges and lessons learnt for implementation

It can be difficult to implement change, but the key is initial engagement from team members. It may be that they do not see an initial benefit so it is important to implement changes gradually and with thought. Look at smaller projects that potentially only affect a few members of the team and when success is shown, innovation can be spread further.

Not being particularly technology minded isn’t a problem – it is about using resources available to streamline approaches and ensure efficient access to services for patients.

For more information contact

Rachel Viggars
Clinical Nurse Lead
Ashley Surgery
North Staffordshire Clinical Commissioning Group
rachel.viggars@northstaffs.nhs.uk