Clinical health coaching partnership with Hartlepool & Stockton on Tees CCG empowers patients

A 15 month project to explore the benefits of clinical health coaching for patients with long term conditions has demonstrated a 50% reduction in unplanned hospitals admissions according to an evaluation by Hartlepool & Stockton on Tees CCG. Launched in 2014, a total of 7 GP Practices in Hartlepool signed up to the service provided by clinical health coaching specialists, Totally Health.

The project aimed to identify a group of patients with long term conditions who would benefit from clinical health coaching in order to meet the CCG’s objectives of providing additional support for their patients with chronic diseases such as Chronic Obstructive Pulmonary Disease (COPD), cardiac failure and diabetes, reduce the numbers of Out of Hours and A & E Attendances and reduce the number of unplanned hospital admissions.

The Totally Health model is proven to complement and support existing health care pathways. It delivers lasting changes for patients, more effective condition management, better compliance with treatment, and an improved interaction with available health services. The visions is to build on proposals to ‘liberate’ the NHS by putting patients at the centre of decision making about their own care, enabling them to have more control over their condition and therefore co-creating better outcomes for them and for health and care systems.

The Totally Health clinical team undertook a review of patients’ clinical records for the period and condition within the service and the comparative period prior to the service starting. Having supported a group of 44patients within Hartlepool via a 15-month programme of one-to-one nurse led ‘phone support, the results of the study showed that clinical health coaching had a significant impact on their interaction with the health system and improved self-management of their condition. Over the programme, 1,813 calls were made to patients and 1,071 clinical sessions were completed. The results showed an impressive:

  • 48% reduction in primary care appointments
  • 47% reduction in contacts with all Health Professionals
  • 46% reduction in secondary care out-patient appointments
  • 44% reduction in community healthcare appointments
  • 25% reduction in attendances at Out of Hours
  • 20% reduction in attendances at A & E
  • 50% increase in the number of patients prescribed a ‘Medication Rescue Pack’
  • 66% increase in the number of patients with a documented COPD review
  • After Clinical Health Coaching, COPD documented reviews increased by 26%

Graeme Earl, Business Management Officer and Commissioner at Hartlepool & Stockton on Tees CCG comments, “Supporting patients to self-manage is one of the most effective ways to create efficiencies within the NHS. Identifying the right patients is the first step to successful outcomes, alongside engaging the primary care team in the clinical health coaching programme to ensure that patients see it as a cohesive service. While we recognise that the patient numbers were small, Totally Health’s programme of clinical health coaching has the potential to deliver impressive results for patients, helping to improve interaction with available health services and reduce the reliance on urgent healthcare services.”

Emma Jane Roberts, Chief Operating Officer at Totally Health adds, “We were delighted to partner with Hartlepool & Stockton on Tees CCG to offer a tailored clinical health coaching solution to provide additional support for patients with long term, chronic diseases. While we recognised that this was a relatively small programme, the trend is in line with our evaluations of all our services across the country. Our approach at Totally Health is to adapt and reflect each person’s level of knowledge, skills and confidence around managing their condition and to increase their knowledge, to empower them and to provide support and influence behaviour changes. To be able to deliver such strong results on this project demonstrates the impact that clinical health coaching could have across CCGs if adopted on a wider scale.”

Feedback from the project was valuable, with individual patient comments in the evaluation including:
“The coach was very friendly and very helpful, the phone call at home was great as I am not very outgoing.”
“Really preferred the telephone service over a face to face appointment or group session.”
“The coach was really supportive and got me through a difficult time.”

Totally Health is a national-award-winning specialist provider of Shared Decision Making and Clinical Health Coaching services, the aim of which is to help individuals make positive changes in their lives which address long term health conditions and wider wellness issues (e.g. smoking and obesity).


For further information please contact Caroline Beswick or Lois Spall at Trinity PR on 020 7112 4905 or email

Notes to Editors:

Totally Plc is listed on London’s Alternative Investment Market (ticker “TLY”). Totally Plc is addressing some of the biggest challenges our country faces in terms of healthcare and the growing demands facing our NHS.

As the population of the UK increases, with people living longer as well as the growth in the number of people living with a Long Term Condition, the demand for high quality, accessible health care services increases. The UK market for NHS outsourced services of this kind is £20 billion.

It is their aim to become the leading provider of out of hospital care and Clinical Health Coaching Services in the UK. These are services that support people to manage their own health better to avoid reliance on urgent GP and hospital services and to support the NHS to meet its targets by providing the highest quality out of hospital care.

Totally Health is a subsidiary of Totally Plc.

Totally Health provides an innovative model of medically driven, and personalised Clinical Health Coaching to help support patients with long term health conditions, improve outcomes and reduce healthcare costs. The service delivers sustainable behavioural changes enabling patients to be educated and confident to self-manage their conditions. This in turn aids long term behavioural change and reduces healthcare reliance, re-admissions and emergency admissions. Totally Health provides the leading Clinical Health Coaching service in England to NHS patients via a number of programmes commissioned by CCGs, using a model that is proven to complement and support existing health care pathways.