HTN Now Awards 2023: digital ICS transformation

Next up we’ve got our finalists from the digital ICS transformation category…

Ethical Healthcare Consulting

Overview: Ethical Healthcare Consulting has designed a common and pragmatic data sharing approach for the South East, supporting advances in diagnostics aimed towards tackling the backlog.

Why? Data does not currently flow easily across ICS boundaries and patient care can suffer as a result.

What happened? Ethical Healthcare Consulting was commissioned by NHS England to develop a blueprint for data sharing across ICSs in the South East region. This included a target architecture that would apply a consistent approach and set of standards to enable cross-border data sharing and work alongside existing initiatives such as shared care records. The architecture included a blueprint for image-sharing using the region’s diagnostic systems and infrastructure to support the Community Diagnostic Centres that are emerging from the region’s acute trusts. The work was split into two parts; firstly developing a data strategy which outlined the data sharing architecture and recommendations for ICSs. Ethical worked on the data strategy with their partners Leicestershire Health Informatics to baseline the region’s current data sharing abilities, engaging with 68 stakeholders in the region over 17 weeks. The second part of the work involved Ethnical developing a diagnostics strategy which could support the data needed for that region’s diagnostic network.

Looking to the future. Once the architecture is implemented, clinicians will be able to access data across the region’s hospitals and patients will no longer need to repeat diagnostic tests when receiving care at different sites. Ethical state that the strategies could provide the blueprint for all of England’s ICSs.


Overview: Stafford and Surrounds CCG worked with HN as part of a randomised control trial, aiming to look at how existing patient data could be used to predict those most likely to attend A&E or need hospital care in the near future, using AI.

Why? Frequent users of A&E and primary care services are having a significant impact on the health system every year. In Staffordshire, local analyses show most chronic conditions will increase by 25-30 percent until 2030.

What happened? Along with looking at how patient data could predict A&E attendances and those who may need hospital care in the near future, the CCG wanted to be able to intervene with targeted clinical coaching to reduce people’s dependence on A&E and GP services. Using HN’s AI-powered predictive analytics, HN Predict, the CCG was able to identify and prioritise people with risk of worsening health conditions in real time by analysing their patient records. The algorithm targeted people who were likely to consume three or more acute hospital beds in the next six months or require an increase in GP-led care. The resulting coaching programme, delivered by HN’s trained clinical staff, was co-created with the patient and focused on motivation, health literacy, self-management and care coordination. 59 percent of the coached patients in the trial reported improvement in mental health, 34 percent in general health and 52 percent in physical health.

Looking to the future. Staffordshire ICS and HN are working together on their Frailty and Healthy Ageing programme to see how data prediction methods could work for patients at risk of falls or those who would benefit from a review.


Overview: Nottingham University Hospitals (NUH) and Islacare are working together within neurology to help patients securely submit videos of their tremors and seizures to the clinical team for review

Why? For years treatment of neurological conditions such as epilepsy has relied on patients attending regular clinic appointments to update the team on the way that their condition is changing.

What happened? Clinicians worked closely with Isla to implement the Isla Visual record and create a seamless mechanism for patients, parents and other family members or carers to regularly update the clinical team on progress. Isla’s web-based platform has been configured to send an SMS to patients or to the person who submitted on their behalf with a secure link to submit information. The process is fully automated with the patient receiving a new link each week. Over 480 patients have used Isla to monitor their Epilepsy at NUH in the past two years with more than 2,400 videos submitted to the platform by this cohort. Among the benefits, NUH note that it will help patients be diagnosed more quickly as they do not have to wait for appointments and enables them to progress along pathways in a more timely manner. It can also mitigate risks around information governance and data security by removing the need to manually store files.

Looking to the future. Isla and NUH say that their collaboration has helped patients to feel confident that the clinical team have sight of any important changes that they experience. Additionally, NUH note ongoing financial implications due to allowing patients to remain at home where appropriate.

Better Ltd

Overview: NHS South West London ICB, on behalf of the OneLondon team, partnered with Better to deliver a shared care planning application that launched in seven months, with end-of-life Urgent Care Plan as the first use case for the integrated care planning platform.

Why? End-of-life care planning is a complex area requiring integration with regional and national systems, connectivity with all point-of-care systems, and access by patients for bi-directional engagement. Capturing and sharing information helps patients receive the outcomes and care that they have requested when they die.

What happened? The digitally advanced Urgent Care Plan enables clinicians and support staff to collaboratively create and constantly update patient care plans. They are created following a conversation around needs and preferences between a healthcare professional, the patient and their family. The new technology, provided by Better’s platform, is underpinned by open health data and low-code tools and works by standardising the way information is captured, providing end users with data modelling tools and supporting services to share information more readily. From the launch until the end of November 2022, 7350 new plans were created using the new platform.

Looking to the future. The solution allows care plans to be shared across London, creating a joined-up system, and improves patient and staff experience going forwards by reducing duplication.

Agilio Software

Overview: Agilio Software aims to provide a one-stop-shop digital solution for ICS operational management needs, alleviating system-wide workforce challenges and empowering healthcare professionals to deliver best quality patient care.

Why? Agilio’s primary care team develops products and technology through clinical expertise and user feedback, with all products, modules, updates and services designed to help healthcare professionals in saving money, time and stress.

What happened? With the main purpose of digital ICS strategy to improve outcomes in population health and healthcare through enhanced collaboration, Agilio’s TeamNet presents a simple, comprehensive solution to help with the process. When TeamNet is deployed, every GP practice has instant access to an individual portal where they can manage their own compliance, information specific to their practice, and workforce/HR tools to manage staff, whilst being able to access relevant information shared by the ICB, PCNs and other practices. TeamNet is now deployed across all 136 Nottingham and Nottinghamshire ICS practices, with the team identifying notable reduction in time spent on revisions of organisation-wide documentation as a result. Other benefits include improved communication and compliance.

Looking to the future. The short and long-term vision for TeamNet is to become the staple solution of digital collaboration for wider healthcare, supporting the resilience of individual practices as well as the NHS as a whole. Agilio has recently been working with ICB clients on scoping out requirements for TeamNet to be used in community pharmacy, optometry and dentistry.

Spirit Health and NHS Leicester, Leicestershire and Rutland (LLR ICS)

Overview: LLR ICS has partnered with Spirit Health to deliver an ambitious virtual ward rollout, supporting virtual wards up in scaling up and improving long-term condition management across 16 clinical areas.

Why? With the current national NHS ambition stating a need to provide 40-50 virtual ward beds per 100,000 patients, LLR recognised the potential for digital technology to transform care and tackle capacity issues.

What happened? System leads and clinical teams identified where virtual wards could have the biggest impact, with pathways including respiratory, heart failure, frailty, diabetes, colorectal cancer, haematology and ambulatory jaundice. The Clinitouch remote monitoring app from Spirit Health is being used across all 16 pathways for system-wide continuity. Patients answer question sets and record vital signs using a tablet device at home; the data is then sent onto clinicians and a RAG rating indicates where care is urgently required, allowing clinicians to intervene or escalate as appropriate. The technology can also link into all respective clinical systems through FHIR integration, enabling quick and secure data sharing. This partnership is built on years of collaboration between LLR and Spirit Health, with some evidence from a Clinitouch virtual ward indicating a 40.3 percent reduction in average length of hospital stay and £1047 savings per patient.

Looking ahead. The next phase will see services deployed across primary care in Leicestershire as well as a focus on improving long-term condition management using digital technology.