achieved hypertension control on average across the PCN
Part of North East London ICB, South One serves a diverse population of 38,000 patients, a significant portion of which are non-native English speakers.
A key priority for the service was driving high levels of engagement. There were also technology barriers to overcome, for example, where patients had limited access to blood pressure monitors.
Suvera designed an end-to-end virtual clinic that delivered structured medications reviews and drove earlier diagnosis. In 23/24, the service evolved to take on full management of the PCN’s hypertension and cholesterol register.
The Suvera care team reviewed patients at risk of harm due to medication errors and those living with severe frailty. An automated call-recall system pre-booked patients in for telephone consultation with a Suvera clinical pharmacist who made any necessary adjustments to medication.
Suvera’s data analytics team also ran searches to identify patients at possible risk of hypertension. Patients were then contacted by SMS and invited to utilise the Suvera App which enables individuals to record blood pressure readings.
Patients could access a full hypertension review of blood pressure, weight/BMI and lifestyle, with goal setting and onward planning. Medication was initiated or titrated as required.
Individuals also received support on how to measure blood pressure or were signposted to pharmacies, if access to monitors was limited. Suvera provided full language translation services where English was not the first language.
Patients on hypertension and cholesterol registers had consultations with a multi-morbidity specialist, discussing management of both conditions with the same clinician. This was to ensure continuity of care and an optimal patient experience.
Suvera completed the 22/23 financial year surpassing Investment and Impact Fund (IIF) targets for SMR01 and SMR01b, achieving 71.4% and 79.9% respectively. An additional 223 patients with hypertension were added to the register, an increase of around 8% of patients who are now receiving appropriate treatment.
23/24 saw maximum achievement for HYP 009 and CHOL 002 and averaged 77.4% for HYP008 and 88.6% for CHOL001. 80% of patients on average have achieved hypertension control, an increase of approximately 800 additional patients at target, based on PCN performance prior to Suvera.
