Pain Points Addressed

• Underdiagnosis - Many patients remained undiagnosed for hypertension and cholesterol

• Poor Control Rates - BP control at just 53% (HYP008) and 69% (HYP009)

• Clinical Capacity - Patients not reviewed for years due to staffing issues

• Patient Engagement - Barriers to access in diverse, multilingual population

• Access Barriers - Language barriers, limited digital literacy, deprivation

• Administrative Burden - Manual coordination of patient reviews

• Medication Safety - Patients at risk of medication-related harm, particularly frail patients

• Register Management - Need for accurate hypertension and cholesterol registers

• Multimorbidity - Managing patients with multiple cardiovascular conditions

The Problem

South One Newham PCN supports a population of around 38,000 people in one of London's most ethnically and linguistically diverse areas, along with Newham being the 3rd most deprived borough in London. The burden of cardiovascular disease is significant, with CVD accounting for 24% of all deaths across North East London. The region sees over 220 deaths each month from heart and circulatory diseases, with a stark deprivation gradient; every one-unit increase in deprivation increases premature mortality by 11 deaths per 100,000 population.

The PCN faced multiple challenges: blood pressure control rates were poor at just 53% (HYP008) and 69% (HYP009), many patients remained undiagnosed or poorly managed for hypertension and cholesterol, and some were at risk of medication-related harm. Language barriers, limited technology access, and wider social determinants created additional obstacles to engagement and care delivery.

Traditional care models were failing to reach this diverse population effectively, with staffing and capacity issues meaning some patients hadn't been reviewed for years. The PCN needed an inclusive, data-driven approach that would be light on workforce demand whilst delivering measurable improvements in cardiovascular outcomes.

The Solution: Virtual-First Care for Diverse Urban Communities

Suvera Services Deployed

• Structured Medication Reviews (SMRs)

• Proactive Virtual Clinical Service (Telephone/Video consultations with home monitoring)

• Targeted Case Finding & Analytics

• Long Term Condition Management

• Multimorbidity Management

• Translation & Language Support

• Automated Recall Technology

• Suvera Patient WebApp (Home data submission and self-monitoring)

• Urgent Case Triage

Implementation Approach

Phase 1: Medication Safety and Structured Reviews

The programme began with Structured Medication Reviews targeting high-risk cohorts. Suvera's clinical pharmacists reviewed patients on potentially harmful medications, including those prescribed NSAIDs without gastroprotection and individuals in care settings. Patients were automatically booked using Suvera's recall technology.

Phase 2: Prevalence Coding and Early Diagnosis

Suvera's analytics team ran targeted EMIS searches across all practice records to identify patients with undiagnosed hypertension. Patients were invited via SMS to the Suvera WebApp where they could submit home blood pressure readings remotely or log data from local pharmacies.

Phase 3: Holistic Virtual Care

Patients received comprehensive virtual consultations covering blood pressure, BMI, lifestyle, and risk factors. Medication was initiated or titrated as needed, with individualised care plans fully coded back into EMIS. Translation services and multilingual support ensured equitable access.

Phase 4: Full Register Management

In 2023/24, the service expanded to include complete management of hypertension and cholesterol registers, with multimorbidity consultations offering continuity of care.

Results: Measurable Impact

Clinical Outcomes

Quality of Care Improvements:

• HYP008 average: 77.4% (up from 53%)

• HYP009: Maximum target achievement (up from 69%)

• CHOL002: Maximum target achievement (up from 69%)

• CHOL001 average: 88.6%

• SMR01a: 71.4%

• SMR01b: 79.9%

• 80% of 4,000 patients on hypertension register now controlled

New Diagnoses:

• 223 new hypertension diagnoses (8% increase)

• Approximately 800 additional patients now within target range

Financial Impact

Direct Cost Savings:

• Cost per patient: £66 traditional vs £20 with Suvera (£46 saving per patient)

• Total annual savings: £184,000

• QOF income increase: £13,485

Return on Investment: Combined with prevention of avoidable hospital admissions and cardiovascular events, these savings offer strong ROI for both the practice and wider system.

Workforce Benefits

• All patient outreach, engagement, clinical reviews, and follow-up handled by Suvera

• Automated call-recall system removed need for manual administrative coordination

• Clinical pharmacists worked within agreed framework with appropriate GP supervision

• Practice teams retained visibility through Planner whilst being freed from direct delivery

• Created capacity for practices to focus on complex care and other priorities

Impact Summary

Over two years, South One Newham PCN transformed cardiovascular care delivery in one of London's most diverse and deprived populations. By achieving 80% hypertension control across 4,000 patients and bringing an additional 800 patients within target range, Suvera demonstrated how virtual-first health care can close health inequity gaps whilst delivering significant cost savings and reducing workforce burden.