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80%
Hypertension Control Across 4,000 Patients
8%
Increase in Hypertension Diagnosis (223 new patients)
£184,000
in Cost Savings to the Practice
South One Newham PCN supports a population of around 38,000 people in one of London's most ethnically and linguistically diverse areas, along with Newham being the 3rd most deprived borough in London. The burden of cardiovascular disease is significant, with CVD accounting for 24% of all deaths across North East London. The region sees over 220 deaths each month from heart and circulatory diseases, with a stark deprivation gradient; every one-unit increase in deprivation increases premature mortality by 11 deaths per 100,000 population.
The PCN faced multiple challenges: blood pressure control rates were poor at just 53% (HYP008) and 69% (HYP009), many patients remained undiagnosed or poorly managed for hypertension and cholesterol, and some were at risk of medication-related harm. Language barriers, limited technology access, and wider social determinants created additional obstacles to engagement and care delivery.
Traditional care models were failing to reach this diverse population effectively, with staffing and capacity issues meaning some patients hadn't been reviewed for years. The PCN needed an inclusive, data-driven approach that would be light on workforce demand whilst delivering measurable improvements in cardiovascular outcomes.
The programme began with Structured Medication Reviews targeting high-risk cohorts. Suvera's clinical pharmacists reviewed patients on potentially harmful medications, including those prescribed NSAIDs without gastroprotection and individuals in care settings. Patients were automatically booked using Suvera's recall technology.
Suvera's analytics team ran targeted EMIS searches across all practice records to identify patients with undiagnosed hypertension. Patients were invited via SMS to the Suvera WebApp where they could submit home blood pressure readings remotely or log data from local pharmacies.
Patients received comprehensive virtual consultations covering blood pressure, BMI, lifestyle, and risk factors. Medication was initiated or titrated as needed, with individualised care plans fully coded back into EMIS. Translation services and multilingual support ensured equitable access.
In 2023/24, the service expanded to include complete management of hypertension and cholesterol registers, with multimorbidity consultations offering continuity of care.
Return on Investment: Combined with prevention of avoidable hospital admissions and cardiovascular events, these savings offer strong ROI for both the practice and wider system.
Over two years, South One Newham PCN transformed cardiovascular care delivery in one of London's most diverse and deprived populations. By achieving 80% hypertension control across 4,000 patients and bringing an additional 800 patients within target range, Suvera demonstrated how virtual-first care can close health inequity gaps whilst delivering significant cost savings and reducing workforce burden.
