achieved control with Suvera who submitted a blood pressure reading
In just six months, Suvera reduced systolic blood pressure by an average 10.3 mmHg per patient and achieved 80% engagement rates in Core20PLUS5 populations.
Individuals reached normotensive range within 16 days on average from initial invite, realising a rapid step-change in proactive prevention of CVD events.
Historically, Lewisham has been one of the lowest performing boroughs in SEL ICB for hypertension achieving 55.12%, 25% below the national ambition of 77%.
Lewisham is also an area of significant health inequalities ranking among the 15% most deprived local authorities in the country. 69% (25,557) of individuals already on a hypertension register in SEL ICB are part of Lewisham’s Core20PLUS5 cohort. Data also indicates that patients not achieving blood pressure targets are more likely to be younger (<60), of Black African or Caribbean background, male and living in the two most deprived quintiles.
SEL ICB aimed to target a group of approximately 5000 patients with hypertension who were either untreated or sub-optimally managed. To address health inequalities, the ICB sought a novel, innovative virtual care solution that could improve both blood pressure outcomes and patient engagement.
Suvera was selected by Lewisham Borough as the digital health partner for delivering proven results in proactive long-term condition management. The service was commissioned via the CVD Prevention Programme.
I think the online clinic is great and takes anxiety out of visiting the clinic
Suvera’s virtual care model was mobilised to support Modality Lewisham PCN and Lewisham Care Partnership, working at scale as an extension of local GP practices. Baseline data for the two PCNs stood at 61.05% and 56.63% respectively for CVDP007HYP.
Suvera risk stratified patient records utilising the UCLPartners’ framework. Patients were invited to enrol in Suvera’s virtual clinic and submit blood pressure readings in the Suvera App. Individuals were then reviewed and managed by Suvera’s experienced team of clinical pharmacists.
What’s unique about the Suvera platform is that it uses automation to boost productivity, offering 3x more patient contacts than traditional models. This ensures patients are engaged and empowered throughout their health management journey. While the Suvera care team specialises in management of complex multimorbidity.
During their review, patients could discuss test results, treatment goals and care plans. GP supervision was also provided by Suvera. Partner practices received comprehensive support and could access Suvera Planner, which provided data insights on patients’ progress in the virtual clinic including targets completed.
Of the 5000 patients invited, almost 70% were within the Core20PLUS5 population. 75% of patients invited were from BAME ethnic groups. A total of 4035 patients engaged with the service while the engagement rate for Core20PLUS5 patients was a similarly impressive 80.8%. Almost 16,000 blood pressure submissions were made by patients and over 1000 lifestyle questionnaires were completed during the course of the programme. 71% of patients said they were likely or extremely likely to recommend the service.
Most importantly, the virtual clinic significantly improved patients' blood pressure. The graph below demonstrates that upon enrolment in the program, Suvera reduced patients’ systolic blood pressure by an average of 10.3 mmHg per patient.
Of patients who submitted blood pressure readings, 70.3% achieved control post-intervention. 52% moved from stage 3 to a lower-risk level, preventing possible CVD events. Patients who were uncontrolled on first reading achieved normal control in 16.4 days on average from invite. A total of 1987 patients were managed to target.
Diving a little deeper per PCN, prior to Suvera in February 2024, Lewisham Care Partnership’s HYP008 achievement stood at 60.5%. Post-intervention, the PCN achieved a maximum completion of 77%. This was also accomplished with fewer patients being exception reported (a reduction of almost 12%) representing an additional 714 patients treated to target range.
Results achieved by this programme point to potentially significant cost savings and reductions in system pressures, CVD events and with it, possible admissions.
Without Suvera, both PCNs would have had to invite all 5000 patients using existing technologies and would expect to engage around 65% of patients (3,250 patients). In primary care, engaged patients would require two consultations to reach target blood pressure control on average. By taking on end-to-end management, Suvera saved a combined total of ~7,500 appointments for the two PCNs. At an estimated cost of £18* per appointment, this equates to £135,000 in savings.
For the non-engaged 35% of the population (around 1750 patients), this cohort would still receive at least three engagement attempts per year. At a cost of ~£20 per patient in administration, searches, recalling patients and SMS messages, this saved an additional £35,000 in time and operational costs through Suvera conducting engagement. This adds up to primary care saving of 170,000 and an ROI of £1.70 from £1.00 invested in the service.
In secondary care, we can model similarly impressive impacts. Data shows a 10 mmHg reduction in systolic blood pressure lowers risk of stroke by 27% and heart attack (coronary heart disease) by 17%. With 2,435 patients managed by Suvera achieving more than a 10 mmHg reduction in systolic blood pressure on average, this could prevent approximately 40 strokes and 25 heart attacks. With each stroke costing approximately £20,000 in the first year alone, the prevention of 40 strokes could lead to £800,000 in savings. Overall there is a conservative saving of £8.00 in secondary care from £1.00 invested with Suvera.
Combining primary and secondary care savings, Suvera’s model delivers a total £9.70 return for every £1.00 spent by the NHS.
Suvera ably achieved ambitions set by SEL ICB, meeting the triple aim of improved care experiences and population health at reduced cost. Supporting hypertension management across two PCNs, Suvera has helped to elevate previous performance on blood pressure targets, and at the same time, successfully engaged target patient populations.
Moreover, results from the programme demonstrate a reduction in GP appointments, secondary admissions and adverse events combined with cost savings across primary and secondary care, illustrating system impact and return on investment.
Graph show stages at which patients improved from first to most recent blood pressure reading
