Enfield South West PCN tasked Suvera to fully manage their hypertensive population. Part of North Central London ICB and with an overall list of 50,000 patients, Suvera significantly improved blood pressure control across practices.

Supporting risk stratification 

At the outset of the partnership, The Suvera team worked closely with the PCN to establish goals for the service. One of the key aims was to help all practices achieve normotensive ranges for HYP 003/007 QOF indicators with a target of 77%. 

Suvera analysts risk stratified populations and engaged patients across the PCN footprint. Individuals were enrolled in Suvera’s virtual clinic, and given support for condition and medication review, alongside care plan development. Patients could submit key health readings in the Suvera app, and were monitored in real-time by the Suvera care team.

Surpassing targets

The service helped to proactively manage hypertension patients, enabling prevention and early intervention at scale. While for practices, the clinic has helped to streamline care coordination, patient outreach and provided additional chronic care capacity to the system. 

As a result, Suvera delivered an average 83% target achievement across all practices, surpassing the target of 77%. More importantly, Suvera achieved significant progression across all practices within the PCN as shown below. 

Leaving no practice behind

HYP003 (QOF Target 77%) – Patients aged 79 years or under with BP 140/90 or less
HYP007 (QOF Target 80%) – Patients aged 80 years or over with BP 150/90 or less