72% of Orthopaedic patients discharged without attending clinic (E028)

Orthopaedic: Supporting Remote Follow up Post Hip and Knee Surgery to Improve Patient Flow (E028)

Flo has been introduced to Sherwood Forest Hospital Foundation Trust to support patient flow across the hospital and offer a safe and convenient alternative to attending the outpatient clinic for follow up 12 months post hip or knee replacement. 

Results show less, but more appropriate, appointments in follow up clinic with clinicians feeling that patients have at least the same confidence as if followed up face-to-face in clinic.

Positive patient feedback was provided and 72.2% of patients were able to be discharged by the nurse remotely without having to attend clinic releasing 490 clinic appointments equating to 24 clinic sessions. 

Carol Turner, Florence Project Manager working across Nottinghamshire supported by the East Midlands Academic Health Science Network was invited to showcase the outcomes at the British Orthopaedic Association Congress 13-15th September 2016 at the Belfast Waterfront Conference Centre.

Carol has also presented the outcomes with Vikram Desai, Orthopaedic Consultant at the ‘Outpatient Services: 2016 Innovative Models’ Conference in Manchester. 


In 2014/15 there were 680 hip and knee replacements carried out at the Sherwood Forest Hospitals NHS Trust impacting negatively on the new to follow up ratio of 1:2.8 which was above the figure recommended by the local Clinical Commissioning Group of 1:2.

An alternative to face-to-face clinic appointments was to exploit the benefits of Flo to provide alternative solutions to patients and clinicians whilst achieving a more cost effective solution to care delivery.

Flo was utilised amongst a cohort of suitable patients (those who match the acceptance criteria) over a period of 8 months, from the initial ‘go live’ date of the 4th September 2015 to 4th May 2016. Patient’s needs were identified before enrolment onto Flo and offered the appropriate protocol and information pack. 

An enhanced referral process was utilised in order to achieve immediate evidence gathering for the purpose of the project. The Flo Project Manager facilitated specific ‘Flo’ clinics to meet with those patients whose 12 month follow up appointments were pending and ensured it coincided with their x-ray investigation so as not to increase their visits to hospital unnecessarily.

The individual patients were given an explanation (verbal and written) of the Flo service and subsequently enrolled onto the system. As Flo can be easily adapted to suit individual needs the timings of the protocol were managed and edited to allow for the text messages to be delivered within a couple of days of the appointment at the convenience of the Patient. 

Apace with this 166 Patients were enrolled onto Flo at their 6 week follow up appointment for their future 6/12 review via Telehealth (see below process map). 

Process Map

  • Reduced number of face-to-face clinic follow-up appointments
    • Flo evaluation feedback questionnaires completed by clinician 

The most reliable and sustainable way to improve both quality and cost is to systematically redesign processes of care’[1]. By utilising Flo Telehealth as a means to review Patients post-operatively it has demonstrated an effective resource for reducing capacity in out-patient clinics and changing practice. 

On the basis of the aforementioned figures, the projection is (based on a total number of hip/knee replacements of 680 per annum [2014]) that 490 clinic appointments could be avoided. 

This equates to approximately 24 outpatient clinic sessions per year for this cohort of patients, allowing for more effective use of clinic resources, staffing and cost savings/avoidance.
Costs/cost avoidance 

Costs/benefits shown below are per patient follow-up


  • It is difficult to give an exact figure for the cost of the service for each individual Team as this is always fluctuating dependant on % patient usage per organisation and apportioned across the 6 CCG’s in Nottinghamshire (the more patients and organisations throughout Nottinghamshire that use Flo, the less the cost per service).

All parties were made aware of the potential constraints/risks that may impact on the successful delivery of the project and the achievement of its objectives. 

  • Patient cognitive ability and willingness to take part 
  • Team members understanding of the Flo system 
  • Time constraints with respect to the collection of the necessary data for evaluation purposes

To ensure that the implementation of Flo suitably demonstrated the impact on the SFHFT Orthopaedic service and its users, a variety of methods were used to facilitate this. 

Improved patient pathways

Flo evaluation feedback questionnaires which are completed by both patient and clinician 

Of the 115 patients who used Flo during the life of the project, patient feedback data was available for 98 (85.2%) patients [50 female, 48 male with an age range of 43-90 years] 

It was evident from the feedback that the implementation of Flo achieved a positive response to the service’s ambition of improving the patient pathway.

Patients strongly agreed/agreed to the following statements: 

‘Florence is improving my overall care experience’- 67.3%
‘I feel that Florence supports the existing care I receive’- 77.6% 
‘I find Florence very convenient’- 88.8% 
‘Florence is easy to use’ – 86.7%
[Those who disagreed with this statement were aged > 65 years who found it difficult to use the texting application on their mobile phone or who relied on a relative to respond for them]. 

78.6% of those patients using Flo ‘believe that Florence should become a standard service in the future’ and 78.6%‘would recommend Florence to a friend or family member’.

Clinician Feedback:-

“Have you had more or fewer contacts with this person because of using Florence?” 
A lot more =0% 
A little more =11.2% 
A little fewer =83.7% 
A lot fewer =1% 
No change =4.1%

“Have your contacts with this person been more or less appropriate because of using Flo?”                      

Definitely more =25.5% 
Probably more =58.2% 
Probably less =3.1% 
Definitely less =3.1% 
No change = 8.1%

“Do you believe the Flo process has given the patient the same level of confidence as a ‘face to face’ appointment would have?” 
Definitely some =33.7% 
Probably some =33.7% 
Probably less =17.3% 
Definitely less =12.2% 
No change =3.1%

115 patients were enrolled onto Flo via the enhanced referral process mentioned earlier. 

The success rate for those discharged without the need for a face-to-face clinic appointment with a Consultant/Specialist Nurse was 72.2% (83 patients); 

Those requiring a clinic appointment was 23.5% (27 patients) and those who remained on Flo for a further follow up at a later date were 4.3% (5 patients).

Case study 

  • A 73 year old lady who was diagnosed with osteoarthritis of her left knee underwent left Total Knee Replacement in March 2015. 

With her agreement she was enrolled onto Flo for her 12 month review as part of the enhanced referral process and consented during a ‘Flo’ clinic at a time convenient to her.

At first she had some reservations, being slightly nervous at the thought of having to reply to the text messages but by having her daughter with her at the time of the receipt of the text messages, she explained that her fears were unfounded and she managed to reply without issue and actually said she thought it was easy to do!

The Nurse Specialist reviewed the lady’s orthopaedic score (which was 36 out of 48) and her x-ray during a ‘virtual’ clinic and discharged her without the need for her to have a face to face appointment.

A previous history of right Total Knee Replacement in 2002 and right Total Hip Replacement in 2012 allowed the lady valuable insight into the improved pathway. She stated she had wished her past experiences could have been as smooth and convenient, particularly as the last time she had been a carer for her sick husband and it would have been far easier via the Telehealth way.


It is often those closest to the processes that are best placed to provide valuable feedback on how current services can be improved. As patients are the ones who experience the process first hand, they have a unique, highly relevant perspective. 

The patient experience in this instance has been a positive one highlighting that there is an understanding that there is a need to change and a willingness to adapt to this change. 

For patients, convenience and choice in accessing their local x-ray department at a time and place that suits them, is not only beneficial to them but also the hospital which avoids the ‘clogging up’ of the radiography department and ultimately reduces the wait in outpatient clinics for others. 

With regards to the financial implications of implementing Flo for the ‘6/12 month joint replacement follow up’ service there has been a reduction of 490 face to face clinic appointments equates to approximately 24 clinic sessions which potentially frees up consultants to see review patients without delays (within the 18 week RTT target).

This could potentially enable the service to increase new patient appointments and/or allows for increased Operating Theatre sessions optimising staff resources/skills. Using the above figures and current tariff payment there is an immediate saving of approximately £14,500 per annum for the local CCG. 

It is still very early days, however, the SFHFT Orthopaedic Business Manager is confident that;

it has enabled the SFHFT Orthopaedic service to be lower than contracted and national average with regards to the new to follow up ratio’.

Carol Turner – East Midlands Academic Health Science Network               

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