Frequently Asked Questions

AICC is a service which applies artificial intelligence (AI) to routinely collected health data, identifying individuals most at risk of requiring emergency hospital stays. These patients are then offered clinical coaching with qualified healthcare practitioners. By proactively identifying and supporting at-risk individuals early, the AICC programme aims to help them to reduce the need of emergency care. By helping more people to receive the right care at the right time, it reduces pressures on the healthcare system.

The AICC service is developed and delivered by Health Navigator (HN) in partnership with the North East London Integrated Care System. 

Clinical coaching, delivered by clinically trained professionals, focuses on empowering patients through supported self-management. They support patients in understanding their conditions, preparing for GP appointments, and developing self-care strategies. It also involves creating personalised plans, over the phone, based on what matters most to the patient, rather than solely focusing on their medical conditions. These plans are tailored to the patient’s medical history and lifestyle, guiding them toward achieving their individual health goals and improving overall well-being.

Health Navigator (HN) has been building, testing, and delivering its service in the UK since 2015.

HN’s Clinical Coaches are registered healthcare professionals, all of whom have worked in clinical roles within the NHS. The service provides telephone-based clinical coaching for up to six months per patient. HN works closely with the healthcare system to ensure its service complements existing care pathways. This includes writing summary clinical reports into the patient record and sending them to GPs to ensure transparency and continuity with other NHS healthcare providers.

As opposed to standard healthcare, where care is delivered by doctors, nurses and allied health professionals in a medical setting for diagnostic and treatment purpose, clinical health coaching uses a proactive, holistic approach to care focused on education, fitting into the patients way of life, and ensuring the right support network from clinicians and social structures. Clinical Coaches do not diagnose medical conditions, change prescriptions, or provide treatments. Patients remain under the care of their GP for all medical needs. 

All clinical coaches receive training via an accredited training programme by the Personalised Care Institute (PCI), with coaches overseen by a Chief Nursing/Medical Office to ensure the highest quality.

Yes, video calls are available if needed. While the clinical coaching service is primarily offered over the telephone, HN can accommodate video calls for patients who prefer this option or when it better suits their needs. 

HN have a clinical hierarchy and safety framework to ensure that patient care is safe and effective. They also monitor the quality of coaching, with coaches being overseen by a Chief Clinical Officer. 

Patients’ complete questionnaires assessing their experience before and after the coaching to understand how effective it’s been. This way, HN can understand what is working well and any areas of improvement. 

HN collects feedback at a series of time points before and after the service from patients receiving clinical coaching. In 2022, HN’s results from over 500 surveys showed that 97% of patients surveyed rated the overall service as ‘Good’ or ‘Very good’, and 96% reported that the service is helping them. Patients who have come to the end of their coaching programme report feeling more confident, empowered, better informed and happier with their health and wellbeing choices. 

An independent evaluation of the AICC programme was conducted in 2021 by the Yorkshire and Humber AHSN (now Health Innovation Yorkshire & Humber). Based on the experiences of patients, the report concluded that HN's clinical coaches helped patients enrolled to the AICC programme, overcome multiple barriers including a lack of understanding or knowledge of the health system, low confidence and low motivation. 

Clinical coaching does not replace GPs or existing care plans but works alongside NHS services to support patients in managing their health. Clinical coaches may liaise with GPs or other healthcare providers, with the patient’s consent, to ensure coordinated care, but generally encourages the patient to do this for themselves. The service is not a substitute for primary, urgent or emergency care. 

HN does not collect any new information about patients for running the algorithm. All the data collected is already held by the NHS and GP practices. HN uses data to build and run an AI tool that can predict, with a high level of accuracy, those people who will be at high risk of attending emergency care services.

To protect patient’s data, each patient's record is anonymised and a secret code is assigned to each patient, which can be seen by the Data Analysts developing the algorithm. High risk patients are assessed by a clinical coach to review if they can take part in coaching, at which point, identifiable data is accessed and then deleted immediately after the assessment is complete. Information that could accidentally reveal a patient's identity is edited for HN. For example, dates of birth are changed to an age. HN only ever has access to the minimum amount of data needed to allow their system to work.  

Data stays within the UK in specialised cloud-based NHS servers. HN temporarily store small sections of data to develop the algorithm, deleting all files after it has been developed.

HN’s services are backed by robust, technical and organisational safeguards, dedicated security and privacy teams. The programme and the software are reviewed annually by third-party auditors.

HN implements advanced data security in line with NHS guidelines. This data security helps to protect data. All information is stored in highly secure data centres. Your data is always encrypted, which means it’s scrambled so only authorised people can read it.  

No, there is absolutely no plan to sell data to private companies. Data privacy and security are fundamental to HN’s operations and ethics. 

Standard NHS opt-outs apply to this programme which allow patients full control over data sharing with third parties like HN. Patients registered in the areas where HN is being launched can contact the company directly to ask for their data to be removed from algorithm development.

In addition, all identified patients are provided an information brochure and consent form from HN as part of the programme. This form states that patient participation is entirely voluntary and can be withdrawn at any time with no requirement to provide a reason or any notice in advance. If a patient decides not to proceed with participating, it does not impact their care within the NHS.

QR codes on patient facing materials will connect patients to the HN website, which will include a dedicated section with clear explanations about what data is shared and with who. This information will support patients with making any opt-out decisions and will be available at GP practices, and in the leaflets and letters sent to patients. 

Patients are identified for coaching by an AI algorithm (or “tool”) that is trained on local healthcare data. The AI tool identifies which patients are most at risk of emergency hospital stays over the next 3 to 6 months. HN clinical coaches will review the results and check them before recommending people for the service.  This means there is always a 'human in the loop' to review and engage with the AI tool. 

HN ensures algorithms are fair and unbiased through rigorous testing, external audits, and human oversight before it is used in practice. The algorithm takes protected characteristics (age, gender, ethnicity) into account and HN will ensure that the team developing the algorithm is diverse, in order to include a variety of perspectives. 

Exclusion criteria for the service is binary to prevent personal bias from coming into the screening. HN will also have transparent consent processes in place and ethical standards for decision making. 

Patients who aren’t selected by the algorithm remain in their standard care pathways, continuing to receive the usual care and support from their GP, community health services, or other NHS providers. 

It’s important to note that the algorithm is run weekly. This means that should any changes occur in a patient’s circumstances—such as a new health event or shift in their risk profile—they could still be identified by the algorithm and offered the service in the future. This ensures that the system remains responsive to evolving patient needs and provides opportunities for inclusion as appropriate. 

Patient information is stored in hospital systems via coding. Although hospitals have different IT systems, coding is similar throughout the NHS which makes it easier to have a standardised approach.  

Both GP and hospital data will be used to develop the algorithm. Therefore, if someone doesn’t attend their GP but does attend the hospital, they will be identified. Having said this, there won’t be data on everyone, and this is a concern that the NHS continues to address, by collecting data and ensuring that this data is accurate.  

Patients will initially receive a letter in the post informing them that they have been identified for the clinical coaching service. HN will then follow-up with a phone call twice, leaving messages informing the patient of who they are. If they are unable to get hold of the patient, the patient will receive a second letter, informing them that they were contacted, and the phone number for them to contact HN, should they want to understand more about the clinical coaching service.  

All letters will have NHS headings to demonstrate that HN is a trusted service and provider for the NHS, working complementary to GPs. GPs will also be informed of the service, so can inform and reassure patients, should they enquire about the clinical coaching service at the GP.  

Involving patients in the set-up and delivery of programmes is of paramount importance and has underpinned HN’s research and evaluation work over the years.  

In addition to ongoing direct feedback from patients enrolled in the AICC programme in North London, a PPIE (Patient and Public Involvement & Engagement) Network will be established to incorporate direct input from the public throughout delivery. 

HN has implemented its AI-identified Clinical Coaching (AICC) service across various regions in the UK, including partnerships with NHS Trusts such as York Teaching Hospital NHS Foundation Trust. In these collaborations, HN's proactive health coaching has led to significant outcomes, such as a 34% reduction in A&E attendances among supported patients; 24% reduction in unplanned admissions and an improved survival, primarily in some elderly males. 

UCLPartners is a health innovation partnership working with healthcare professionals, researchers, patients, industry and innovators to tackle the biggest health challenges facing our communities. We are providing support to make the programme as successful as possible, connecting HN with communities across North East London and the NHS system to develop a collaborative approach, involving the people who will experience the impact of the project.