Case study: Multiple conditions app transforms long-term condition management


Torbay and South Devon NHS Foundation Trust develops solution to help manage multiple pathways of care

The challenge

Escalating demand and pressures on the NHS are well documented, but what is often not publicised is that currently one in four people in the UK have two or more long-term health conditions, a number predicted to double by 2035.

This poses a huge challenge to the healthcare system with an estimated £7 in every £10 being spent on treatment and care for people with long-term conditions.

And estimates suggest that someone with three or more conditions will need NHS funding amounting to approximately £8,000 a year.

This app extends the reach of our support, but also puts care into the hands of patients

Long-term conditions also equate to 50% of all GP appointments, 64% of hospital outpatient appointments, and 70% of all hospital bed days.

The solution

Acting on the significant opportunity to impact outpatient activity using digital tools, Torbay and South Devon NHS Foundation Trust has used a unique collaborative approach to develop an app that is set to transform planned care services.

The CONNECTPlus app has been developed through the trust’s unique partnership organisation, Health and Care Innovations LLP (HCI), and provides a central place for patients and clinicians to manage multiple pathways of care.

The app was first piloted in rheumatology in 2018 and then in MS (Neurology) in 2019 and has been developed with co-design input from patients and their clinicians.

It enables users to learn about their condition and care pathway through indepth information and video content created with NHS clinicians, track their progress through symptom trackers, as well as manage medication and appointments.

And it provides a dashboard for clinicians to view one patient’s, or a cohort of patients’, progress and compliance.

The impact

Early evaluation in rheumatology showed a reduction in appointments of up to 50% and seven hours of weekly nursing time released from the education programme for patients being prescribed new medications.

It reflects the range of services provided and is fast becoming a ‘hospital in your pocket’ for many patients by providing all the information they need in one place

In addition, within six months the trust also saw diminished waiting times for MS clinics.

Dr Matt Halkes, clinical director of innovation and digital transformation at the trust, said: “This app extends the reach of our support, but also puts care into the hands of patients.

“It reflects the range of services provided and is fast becoming a ‘hospital in your pocket’ for many patients by providing all the information they need in one place.”

Future development

2021 brings an accelerated approach to the development of CONNECTPlus and forms a key part of Torbay’s digital transformation strategy.

Working closely with the trust’s long-term conditions operations manager, additional conditions across multiple pathways will be added, including heart failure, asthma, pulmonary rehabilitation and diabetic foot.

There have been 50 foot amputations in Torbay in the last four years, a procedure that currently costs the NHS £75,000.

CONNECTPlus will be used as part of a prevention project that focuses on remote patient education relating to foot care in diabetes.

By providing the information needed to improve foot self care and identifying and raising awareness of potential risks and foot ulcers, it is hoped that deterioration risks will be reduced.

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Other conditions being added in 2021 are from HCI’s project work with NHSE’s national Outpatient Transformation Programme and include:

  • Hip and knee osteoarthritis: Through funding secured by Devon CCG via NHSE South West, CONNECTPlus will be used by patients with hip and knee osteoarthritis in Torbay and South Devon to access a virtual joint school and physiotherapy programmes to reduce the trust’s follow-up consultations by 80%, releasing at least four hours of Band 6/7 AHP time per week. This will be accompanied by the integration of data from a wearable device to track post-operative mobility
  • Gastroenterology: IBS symptoms are a common cause for referral into secondary care from GPs, but around 98% of cases were found to be treated by diet. This has caused the dietetics department to become overloaded with increased referrals. CONNECTPlus will be used to provide patients with the assured prescribed information around basic and more-complex diets without the need for a face-to-face appointment
  • Ophthalmology: There is currently a huge backlog and growing waiting list for cataract procedures. CONNECTPlus will be used to assist the effective continuation of remote pre-operative assessments with the production of new video content to explain surgical risk, consent, and post-procedure care. This can then be used to shorten or replace information-giving appointments. Further work in ophthalmology with Moorfields, NHSE, Manchester Eye Hospitals, and Glaucoma UK will see CONNECTPlus used in a testbed site in Wales for delivering a programme of support that educates patients on AMD and glaucoma, part of the National Outpatients Transformation Programme