Summary

Cape Hill Medical Centre serves one of England's most deprived communities, with most patients ranking in the 1st and 2nd most deprived decile nationally. Despite significant barriers including language diversity, limited digital literacy and housing insecurity, the practice achieved exceptional engagement rates and clinical outcomes through Suvera's virtual-first care model. 

The partnership demonstrates that with the right approach, high-quality long term condition care can be delivered equitably across all deprivation levels, with the most deprived patients showing the strongest improvements.

The Problem

Cape Hill Medical Centre faced the dual challenge of serving a deprived practice population whilst managing long term conditions without a structured recall system. The practice was caught in an exhausting "end-of-year rush" cycle, scrambling to meet quality targets without proactive planning or coordination.

The practice's diverse population faced multiple barriers to care: language differences, limited technology access, digital literacy challenges and housing insecurity created additional obstacles to engagement. Traditional care models were failing to reach the patients who needed support most.

Without a systematic recall methodology, the practice lacked the infrastructure to deliver consistent, proactive care. Cape Hill needed a solution that could overcome significant barriers to engagement whilst being light on workforce demand: delivering measurable improvements in a challenging healthcare environment.

The Solution

Cape Hill Medical Centre partnered with Suvera to implement a comprehensive, end-to-end strategy for long-term condition management. Suvera's Proactive Virtual Clinics replaced the end-of-year scramble with systematic, coordinated care delivery across multiple conditions simultaneously.

Conditions Managed

Suvera supported Cape Hill Medical Centre both with national QOF targets but also local DES requirements, known as PCCF:

• Hypertension (QOF)
• Cholesterol (QOF)
• Diabetes (QOF and PCCF)
• Asthma (QOF)
• Non-diabetic hyperglycaemia (QOF)
• Medicines Optimisation LES (PCCF)
• CVD (PCCF)

Implementation Approach

Risk-Stratified Recall System

Suvera implemented a clinically-driven recall methodology, prioritising patients with multiple long-term conditions and those at highest clinical risk first. The automated Planner system replaced Cape Hill's manual coordination with a systematic, proactive process that maximised clinical impact. Multi-channel engagement, including SMS invitations and postal letters, ensured 87% engagement despite high deprivation and limited digital access.

Prevalence Coding & Register Management

Suvera's analytics team ran targeted EMIS searches across practice records to ensure accurate disease registers and identify patients requiring review, improving the completeness and quality of clinical data.

‍Holistic Multi-Condition Care

Rather than separate appointments for each condition, Suvera delivered comprehensive consultations addressing all relevant long-term conditions simultaneously. Translation services and multilingual support ensured equitable access across Cape Hill's diverse population, whilst the virtual-first model with home monitoring options overcame barriers related to digital literacy, language, and deprivation.

Seamless Integration

All clinical reviews, medication adjustments, and care plans were fully coded back into the practice system, ensuring complete documentation and seamless continuity between Suvera's virtual care and the practice team. The service integrated within Cape Hill's existing workflows without disrupting established processes.

Results

Patient Engagement

Despite serving the 2nd most deprived practice population nationally, Cape Hill achieved remarkable engagement rates:

• 87% recall engagement rate across all patients
• 77% clinical engagement rate - demonstrating successful conversion from initial contact to completed care

Consistent engagement across deprivation levels proved Suvera’s model for equitable access regardless of socioeconomic circumstances.

Clinical Outcomes

Cape Hill achieved exceptional clinical outcomes across all managed long-term conditions, demonstrating the effectiveness of coordinated, multi-condition management. Patients achieved clinically significant reductions in blood pressure, HbA1c, and improved asthma control.

Baseline indicators

Hypertension

There was an average systolic BP reduction of 8.19 mmHg across hypertensive patients, with the strongest impact in most deprived groups: patients in deprivation deciles 1-2 (429 patients) achieved an 8.32 mmHg reduction

Diabetes

Average 7.5mmol/mol reduction in HbA1c for diabetic patients.

Asthma

Suvera engaged 373 asthma patients, with 319 becoming QOF complete.

Financial Impact

Managing 2,241 patients across multiple long-term conditions through Suvera's virtual-first model delivered substantial cost savings across the entire patient journey.

Without Suvera's coordinated approach, traditional engagement would have generated approximately 65% engagement, requiring significantly more clinical appointments and intensive recall efforts for non-engaged patients. Suvera's support meant:

Appointments Saved:

• 3,362 appointments avoided through efficient virtual care delivery
• 840 hours of clinical time saved (based on 15-minute appointments)
• 327 hours saved in non-clinical engagement work - automated recalls, patient outreach, and coordination

Cost Savings:

• £60,516 in saved appointment costs (3,362 appointments × £18*)
• £15,680 in saved administrative engagement costs (£20 per patient**)
• £76,866 total cost savings

*£18 is a blended cost of mixed workforce delivering consultations (HCAs, Nurses, Pharmacists, GPs with costs of physical estates, where required).

**Administrative costs include running searches, generating lists, recalling patients, SMS messages, and coordination work.

The practice saw improvements in QOF earnings across all conditions managed by Suvera, which also contributed to increased practice income.

Workforce Benefits

Suvera's automated recall system and proactive year-round approach fundamentally transformed Cape Hill's operating model. The practice moved from reactive, last-minute scrambling to systematic, planned care delivery - eliminating the stress and inefficiency of end-of-year target chasing.

Comprehensive Service Delivery

• Automated call-recall system removed the need for manual administrative coordination
• Virtual clinical consultations across four conditions delivered by Suvera's clinicians
• Multi-condition management in single consultations improved efficiency and patient experience
• Translation services ensured equitable access across diverse populations

Maintained Clinical Oversight

Suvera's clinical team worked within an agreed framework with internal GP supervision. Practice teams retained full visibility through Planner whilst being freed from direct delivery, and all care plans and clinical decisions fully coded back into the practice system

Capacity for Complex Care:

With 1,167 hours of capacity returned to the practice, staff were able to:

• Focus on complex patients requiring face-to-face care
• Address other clinical priorities beyond routine LTC management
• Provide continuity of care for patients with needs beyond standardised reviews
• Reduce staff burnout associated with end-of-year rushes and fragmented care delivery

The transformation from chaotic end-of-year management to seamless year-round care represents not just operational efficiency, but a fundamental improvement in staff wellbeing and professional satisfaction.

Case study period: 2024-2025
For more information about Suvera's long term condition management services, contact our team at partnerships@suvera.co.uk