What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?

Health & wellbeing coaching can improve health related outcomes by working with people to set personalised goals and change their behaviours, including those waiting for other investigations/interventions.

It can be effective in prevention and management of many long term conditions, including respiratory, cardiovascular (including T2DM), and stress/low mood. It can also support people with weight management, diet and increasing activity levels.

Many GP Practices/PCNs have struggled to hire HWB coaches, and employed coaches often have very large caseloads and long waiting lists, limiting scalability.

Holly Health (a 2023 member of the NHS Innovation Accelerator) is an app-based digital service that provides scalable coaching, but still in a supportive and personalised way.

Outcomes from 20,000+ users at 100+ GP Practices show statistically significant improvements in Exercise, Self Confidence, Energy, and ONS4 Wellbeing scores.

Indicative data also shows that patient feel more able to self manage, and feel less reliant on their GP practice for support.

What does your project aim to achieve?

• Improve access to health and wellbeing coaching, for a much larger proportion of the practice population
  • Help patients with motivation, self confidence, and sustainable behaviour change
  • Observe any effects on modifiable risk factors eg HbA1C, BP, cholesterol
• Demonstrate scalability and cost-effectiveness
• Improve patient’s ability to self manage symptoms of long term conditions
  • Thus reducing demand for appointments/clinician time
• Help social prescribers/HCAs/nurses/doctors manage their caseloads
• Proactively supporting people before they develop preventable disease/illness
• Provide a non-threatening, low barrier of entry service for patient groups that are more reluctant to engage with current healthcare services
  • This project will also allow us to investigate barriers to health engagement amongst populations
• Offer supported get-started process to assist Digital Inclusion
• A web/SMS version of the coaching app is in development – this project can help identify challenges and solutions to improve Digital Inclusion

How will the project be delivered?

At North Wood Group Practice, patients can be booked into a weekly clinical session introducing Holly Health coaching. There will be proactive outreach to patients who may benefit – eg. prediabetes.

Baseline and subsequent outcomes data is collected in-app, measuring changes in Exercise, Energy, Self-confidence, Sleep, ONS4 Wellbeing scores etc.

We will also observe EMIS data such as BP, HbA1C, QRisk, patient encounters – all personal data is kept and looked at internally at the practice.

The app is fully accredited with DTAC clinical safety/risk, data protection, security and accessibility standards.

The project will allow us to see if existing self reported data suggesting users become less reliant on their GP Practice translates to measurable changes in healthcare demand.

Cost of licensing of Holly Health app is very low – between 15p-30p per patient per year. If outcomes meet the existing data then this would be a very cost effective and sustainable service.

How is your project going to share learning?

• Demonstrate a sustainable cost-effective service that can easily be replicated at other GP Practice, PCNs or wider primary care.
  • Potentially translatable to other fields eg. post-surgery after-care, rehabilitation, medical optimization for surgery
• Demonstrate an unmet clinical need for more proactive lifestyle change, and disease prevention
  • demonstrate a scalable digital service that can impact population health management