Developing a healthcare messaging service

When ChatHealth was first developed, it was recognised that a bespoke technical solution was required to enable the safe delivery of an efficient messaging service. The traditional practice of healthcare professionals using their allocated work telephone handsets to send and receive text messages to and from service users was becoming increasingly common. However, the Leicestershire Partnership NHS Trust leadership did not feel comfortable with this method because it raised risks for the service user, the healthcare professionals and the service overall. For example, access to services was inconsistent; individual staff were not always able to respond; and service users were not aware if the individual staff member they were messaging was working, off sick or on leave.

Because ChatHealth involves a service user sending a simple message from their mobile phone to a secure central inbox, the healthcare team can share the responsibility of managing responses to messages. This also means that staff are engaging with service users using a team approach, which assists with the effective sharing of resources and capacity. The messaging portal was co-designed with healthcare professionals, stakeholders and service users to ensure it was safe and effective for all. Alongside the development of the technology itself, engaging and supporting healthcare professionals to deliver ChatHealth was essential.

ChatHealth is recognised by NHS England and has been part of the NHS innovation accelerator programme since 2019. All innovations selected to join this programme undergo vigorous scrutiny involving expert assessors from several organisations, including NHS England, NHS Digital, Academic Health Science Networks, the National Institute for Health and Care Excellence (NICE) and The Health Foundation (Palmer 2019a).

ChatHealth is not designed to replace face-to-face care, which in the author’s clinical experience will still be more appropriate for some individuals, such as those with severe and enduring mental illness.

ChatHealth roll-out

When Leicestershire Partnership NHS Trust developed ChatHealth, the key drivers were to enhance the care provided to service users and to provide service users with a choice regarding how they access services. The service was piloted in 2012-13 with 3,500 young people across three schools, and following this the trust began providing ChatHealth within its school nursing service. Several outcomes were documented, with Endicott and Clarke (2014) recognising that the service was ‘helping school nursing to become more widely available, particularly to young people for whom this service may be the only access to healthcare’.

Leicestershire Partnership NHS Trust shared its experiences with other school nurses and school nursing services via social media, national school nurse forums, conferences and relationship-building with other school nursing services and provider organisations. School nursing services around England began to recognise the positive outcomes that ChatHealth was having for service users and services alike, and supported the roll-out of the service nationally.

The roll-out of the ChatHealth service to other NHS trusts and healthcare organisations began in 2015, when school nursing teams across the country began to incorporate it into their school nursing services. In 2016, soon after the national success of ChatHealth within school nursing, a pilot of the service was carried out by Leicestershire Partnership NHS Trust’s health visiting service, then it was subsequently launched across the trust’s entire health visiting service. This pilot demonstrated that, if given the choice, parents and carers would use a text messaging service to seek advice and support from health visitors (Palmer 2019b). As with school nursing, the use of ChatHealth in health visiting created a blueprint for health visiting services in other localities.

ChatHealth and mental health support

Salaheddin and Mason (2016) suggested that barriers to accessing mental health support include: challenges in identifying and communicating distress; stigmatising beliefs; shame; a preference for self-reliance; and anticipation that help will be difficult to access. The researchers also emphasised that although mental health issues are prevalent among young people and are associated with various adverse effects, there is a concern that young people infrequently seek help (Salaheddin and Mason 2016). In addition, from March 2020, young people have had to manage the effects of the COVID-19 pandemic, which may have exacerbated existing mental health conditions, contributed to new mental health issues and placed a huge strain on already stretched mental health services. A report by the charity YoungMinds (2021) identified that 67% of young people aged 13-25 years believed that the pandemic would have a long-term negative effect on their mental health.

Table 1 shows the types of enquiries received from young people contacting local ChatHealth messaging services across the UK before and during the pandemic. It indicates that within school nursing most of these enquiries were related to emotional health, and that type of enquiry increased during the COVID-19 pandemic.

Across the UK, increased enquiries about mental health from service users on ChatHealth, as well as the recent uptake of ChatHealth by perinatal mental health and young people’s mental health support services, showed that the use of messaging services could be an effective way to enhance access to mental healthcare.

Anonymous service user feedback from young people’s messaging conversations across the UK was captured for the period November 2019 to March 2020, with service users being asked at the end of each session: ‘Has this conversation helped you – yes or no?’ Around 88% (n=442/502) of respondents replied that the system had helped them, with one young person stating:

‘I love that it’s anonymous and that it’s a texting service. This means you can openly talk about your problems freely without feeling nervous.’

Challenges to digital transformation

Delivering digital healthcare is sometimes approached with apprehension by healthcare professionals, particularly when it relates to sensitive topics such as mental health. In the experience of the ChatHealth project team at Leicestershire Partnership NHS Trust, delivering digital healthcare can potentially take healthcare professionals outside of their ‘comfort zone’. Not only do they have a new piece of technology to learn, but also digital interactions can initially feel unnatural. This is particularly the case where care has been predominantly delivered face-to-face and where people’s body language, presentation (for example how they are dressed) and other cues, such as eye contact and tone of voice, have an important role in rapport-building and the assessment of a service user.

Despite these challenges, the ChatHealth project team have found that when staff members were supported throughout an implementation process they felt empowered and were willing to embrace change. Staff recognised that not only did ChatHealth offer direct engagement with service users, but it also enabled them to contact more service users than before. In addition, in some ways, ChatHealth enhanced face-to-face care because many service users’ issues could be managed by messaging alone, thereby releasing more time for face-to-face appointments for those who really need them.

For any healthcare service, moving to digital healthcare must be a considered and informed decision and not introduced as a tick-box exercise. Rather than a ‘one-size-fits-all’ philosophy, healthcare services need to take a blended and person-centred approach to care delivery. For example, a service user may initially contact a healthcare professional via a messaging service such as ChatHealth, but then move on to telephone consultations, before requesting a face-to-face appointment.

Another issue is that some service users will be digitally excluded, and as such are at greater risk of not accessing services and deteriorating health outcomes. For example, according to NHS Digital (2019): ‘Eleven million people (20% of the population of the UK) lack basic digital skills, or do not use digital technology at all. These are likely to be older, less educated and in poorer health than the rest of the population.’ In its Online Nation report, the UK’s communications regulator Ofcom (2021) provided examples of those who may be digitally excluded, such as:

The Ofcom (2021) report also detailed how the COVID-19 pandemic has created a significant digital divide between those with access to the internet and smartphones, and those who do not have access to technology. The report suggested this disparity in access to online services meant that the first lockdown in 2020 ‘had a greater effect on people who are digitally excluded’. Therefore, it is essential that healthcare services take digital exclusion into consideration and are flexible and adaptable in how they provide and develop their services (NHS Digital 2019). Furthermore, the NHS Long Term Plan (NHS England 2019) states that: ‘people will be empowered, and their experience of health and care will be transformed, by the ability to access, manage and contribute to digital tools, information and services.’

Conclusion

There has been a rising demand for digital healthcare services in response to the COVID-19 pandemic. ChatHealth is a safe and effective digital messaging tool, which provides service users with choice in how they access healthcare services outside of traditional face-to-face care provision.

By implementing ChatHealth, healthcare services can expand service users’ access to services and support them in navigating the complex healthcare system. However, ChatHealth is not designed to replace face-to-face care, which will still be more appropriate for some individuals, such as those with severe and enduring mental illness.