Woodlands Medical Practice

Delivering on-demand chronic care capacity for Woodlands Medical Practice

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patients referred on-demand

A GP practice in North London enlisted Suvera to improve long-term condition outcomes in October 2023. Suvera has helped to manage hypertensive patients’ blood pressure to target while freeing up surgery resource, and provided additional capacity where required.

The need for a flexible solution

The practice team wanted a dynamic service that could scale to demand.

Serving a 5000-patient list size, the team were keen to explore solutions that would benefit their patients without increasing GP workloads. Hypertension management was the biggest priority for the practice team, with over 1500 patients requiring blood pressure checks and more than 600 patients on the practice register.

Successfully engaging elderly and deprived patient populations

Successfully engaging elderly and deprived patient populations

Previously, it was a struggle to review all our patients who needed medications up-titrated. With Suvera, we now have a solution that provides extra support to those who need it most, while also easing pressure on practice clinicians. Patients are giving great feedback, engaging well with the virtual clinic and we’re seeing great outcomes.”

Sangeeta Agheda

Streamlining processes and improving pathways

Before Suvera, the practice had a system in place where patients were booked into lunchtime blood pressure clinics with reception or a healthcare assistant.

However, where individuals presented to the clinic with high blood pressure, there was no clear onward pathway to send patients, with GP and PCN pharmacist clinics often booked up for weeks. In these scenarios, patients would see a duty doctor and medication would often need to be up-titrated with little time for a formal review.

In response to these issues, Suvera mobilised a live referrals service for hypertension management where the practice can refer patients into a virtual clinic, on-demand.

A specialist long-term conditions service

There, patients are reviewed by an experienced clinical pharmacist specialising in long-term conditions. Medicines are optimised as required, with minimal task back to surgeries. Suvera also takes care of patient engagement, collating condition data and chasing up blood tests when needed.

In just six months, the service has completed over 50 live referrals and seen good engagement with 30% of patients contacted submitting a blood pressure reading. Suvera has saved a significant amount of admin time for the practice too with all data coded directly into the practice system. The service has achieved a -17.55 mmHg average change in systolic blood pressure.

Effectively managing patients’ blood pressure to target