Adopting remote monitoring via telehealth in your CCG's practices - part 2: inhaler reminders

In January NHS Stoke on Trent made a free offer to other CCGs to trial a simple telehealth application, Florence or 'Flo'.

Professor Chambers: 'Better compliance should minimise exacerbations of their condition.' Cartoon: Chris Chambers
Professor Chambers: 'Better compliance should minimise exacerbations of their condition.' Cartoon: Chris Chambers

Last week, Professor Ruth Chambers looked at hypertension. This week she discovers how telehealth can help patients with inhaler reminders.

Long-term conditions

A GP practice that wants to set up remote monitoring of patients with long-term conditions in a productive way is likely to focus on the majority of patients with relatively stable long-term conditions or adverse lifestyle habits, rather than the high-risk patients who are under the care of community nursing or specialist services (eg cancer, severe respiratory).

So mobile phone texting or emailing might be the type of telehealth approaches they’ll select –  simple and easily accommodated into their clinical management and popular with their patients, especially if text costs are covered by the NHS.

The Florence (or Flo’) telehealth service meets all these attributes and is currently being rolled out in a national pilot in 33 CCGs across England with the CCG licences and most other costs covered by project resources – so no charges for GPs or their patients.

Table 1 describes the application of the Flo telehealth mobile phone texting service in relation to automated reminders to patients with asthma or COPD. Better compliance should minimise exacerbations of their condition which would be unlikely to have occurred if they had taken their preventer inhaler regularly.

This version has been devised to suit adults or teenagers; but a revised version can remind a parent to organise their child to take their preventer inhalers. Ensure that a teenager aged under 16 years old is competent to take responsibility for adhering to the Flo texts; or add a parent reminder in parallel.

Table 1: example protocol for Flo telehealth application for reminders for inhaler therapy - asthma or COPD


  • To improve patient compliance with inhaler use.
  • To support dual management plan agreed with GP practice, empowering  patient to take responsibility for adherence to agreed inhaler treatment.

Selection of patients

  • Patients with asthma or COPD who forget to take preventer inhalers
  • Adult or teenager aged 13 years or older (you can adapt as alternative version for children/parents)

Success criteria

  • 50% of participants use their preventer inhalers regularly


  • Twice daily reminders to take preventer inhaler for three months
  • Monthly text enquiry of patient experience

Evaluation (optional) – capture of healthcare usage

So is the effort of applying Florence telehealth worth it? Well yes, it should be. Table 2 gives some desirable outcomes – clinical, patient-centred, organisational and financial. There is good evidence that: preventive inhaled medication properly used improves patient outcomes, is cost effective, and reduces demand on high impact areas of healthcare use eg hospital emergency admissions.1,2

Table 2: expected outcomes from application of Florence telehealth for reminders for inhaler therapy

1  Changes in healthcare usage:           

  • Fewer avoidable hospital admissions or A&E attendances; less face to face contacts at GP surgery for emergency consultations.
  • Increased use of preventer inhalers; reduction in reliever inhaler usage.

2  Patient empowerment:                      

  • Greater confidence about their condition.
  • Willingness to change their lifestyle and take their inhalers regularly (right inhaler, right time).

3  Improved clinical outcomes:

  • Adherence to best practice guidelines concerning use of inhalers.

4  Popularity of Flo:     

  • Patients find Flo messages helpful.
  • Clinicians find Flo reinforces clinical management without excessive clinical time.

5  Cost effectiveness:   

  • Reduction in costs of secondary care use (ie avoidable admissions, outpatient referrals).

Table 3 illustrates how these outcomes described in Table 2 translate against the five domains of the NHS Outcomes Framework.

Table 3: Match of Florence telehealth service for inhaler reminders- with NHS Outcomes  Framework


Eg Indicator / Outcome

Florence telehealth foci

Domain 1: Preventing people from dying prematurely

Reducing premature mortality from major causes of death

Asthma – preventive inhaler reminder

Domain 2: Enhancing quality of life for people long-term conditions (LTCs)

Reducing time spent in hospital by people with LTCs

Asthma/COPD: inhaler reminder/ prevent deterioration

Domain 3: Helping people recover from episodes of ill health

Emergency admissions for acute conditions that should not normally require hospital admissions


Asthma/COPD: inhaler reminder


Domain 4: Ensuring that people have a positive experience of care

Enhancing patient experience of primary care


As automated message to all Florence protocols

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

Medication ‘errors’ causing serious harm


Medication reminder (could be inhaler/standby by rescue medication for COPD)



1. Gamble J, Stevenson M, McClean E, Heaney L. The prevalence of nonadherence in difficult asthma. Am J Resp Crit Care Med 2009; 180 (9): 817-22.

2. DH. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England. London: DH, 2011.

  • Professor Chambers is GP clinical director of practice development and performance at NHS Stoke on Trent CCG. Acknowledgements to Phil O'Connell, the innovator of the Florence service and NHS Stoke on Trent CCG

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