Pain Points Addressed

• Underdiagnosis - Devon ICB 14% behind national hypertension ambition
• Clinical Capacity - Lack of capacity for consistent patient review and follow-up
• Patient Engagement - Socioeconomic access challenges, transport limitations
• Administrative Burden - Need for scalable model without burdening existing teams

The Problem

Waterside Health Network PCN serves a coastal population of 71,326 in Devon. The PCN covers areas of significant deprivation (IMD decile 2-3), and cardiovascular disease remains a major health burden, with Devon ICB sitting 14% behind the national hypertension management ambition. Nationally, only 40% of adults with hypertension are both aware of their condition and controlled to guideline levels.

The PCN faced three critical challenges: under-diagnosis and poor control of hypertension in a deprived population, access to healthcare being limited by transport and deprivation, and insufficient clinical capacity to consistently review and follow up patients at scale.

Left untreated, high blood pressure increases stroke risk by 27%, coronary heart disease by 17%, and all-cause mortality by 13%. The PCN needed a scalable, efficient model to improve engagement, identify untreated cases, and achieve sustained control across its dispersed population without requiring additional effort from existing clinical teams.

The Solution: Overcoming Coastal and Deprivation Barriers Through Digital Innovation

Suvera Services Deployed

• Hypertension Management
• Proactive Virtual Clinical Service (Telephone/Video consultations with home monitoring)
• Targeted Case Finding & Analytics
• Translation & Language Support
• Automated Recall Technology
• Suvera Patient WebApp (Home data submission and self-monitoring)
• Urgent Case Triage

Implementation Approach

1. Targeted Case Finding Suvera's data team segmented patients based on cardiovascular risk using EMIS clinical data, prioritising those with historical blood pressure readings and previous cardiovascular events.

2. Multi-Channel Patient Outreach Patients received personalised SMS invitations linking to the Suvera WebApp for home blood pressure submissions. A trial of letter invites alongside SMS improved engagement by 7% at one site, engaging 300+ additional patients. Phone support was available for technical and clinical questions.

3. Holistic Virtual Consultations Suvera clinical pharmacists delivered comprehensive hypertension reviews covering blood pressure, BMI, lifestyle discussions, medication optimisation, and personalised goal-setting. Multi-morbidity consultations enabled single-clinician management of complex cases.

4. Ongoing Monitoring and Rapid Triage Weekday telephone support and asynchronous data review ensured continuous care. The team handled 237 urgent cases within 24 hours, ensuring timely intervention and avoiding risk escalation.

Results: Measurable Impact

Clinical Outcomes

Patient Engagement:

• 1,897 patients invited to join the service
• 1,017 submitted blood pressure readings (75.7% engagement rate)
• 60.3% engaged clinically (shared data or attended review)
• 67.7% of those engaged completed full hypertension reviews

Quality of Care Improvements:

• HYP008: 605 of 871 patients managed to target (69.5% control rate)
• HYP009: 125 of 146 achieved target control (85.6% success rate)
• Average systolic BP reduction: 7.87 mmHg in uncontrolled patients

Clinical Risk Reductions (per NICE guidelines):

• Stroke risk reduced by 27%
• Heart failure risk reduced by 28%
• Coronary heart disease risk reduced by 17%

Financial Impact

Direct Income and Savings:

• Additional income from Devon ICB Locally Commissioned Scheme: ~£34,000
• Avoided GP and nurse appointments through virtual follow-up: £87,262 saved
• Improved QOF achievement contributing to enhanced PCN earnings

Efficiency Gains:

• 237 urgent cases managed virtually, potentially avoiding A&E escalation
• More efficient clinical time allocation through virtual pharmacist reviews
• Early intervention preventing costly downstream complications

Workforce Benefits

• All patient outreach, clinical reviews, data submissions, and follow-up handled by Suvera
• Automated invitations and recall eliminated manual booking requirements
• Translation services reduced communication barriers
• Practice visibility maintained through Suvera Planner without direct delivery burden
• GP time freed for complex care and routine practice priorities

Impact Summary

Over one year, Waterside Health Network PCN achieved exceptional patient engagement (75.7%) across coastal geography, delivering clinically meaningful blood pressure reductions and managing over 600 patients to hypertension targets. The service generated £121,262 in combined income and savings whilst handling urgent cases within 24 hours, demonstrating how virtual care can overcome geographic barriers to deliver both clinical and financial outcomes.