General practice faces unrelenting pressure. In November 2023 alone, GP surgeries delivered 31.4 million appointments.1 That statistic stands as a record for the time of year, an achievement made even more remarkable as the number of permanent full-time equivalent GPs has continued to fall.2
Within the current landscape, managing the UK’s chronic disease burden poses one of the biggest ongoing challenges for primary care. Long-term conditions are estimated to account for more than half of GP appointments and hypertension is a significant contributor both in itself and as a leading risk factor of disease.3
Indeed, it is estimated that one in four adults have high blood pressure and hypertension. The impact on GP appointment numbers? Approximately 12% of all GP visits are attributed to hypertension.4
Tackling ‘the silent killer’
In the search for solutions, optimal models must focus on earlier detection, prevention and intervention. At the same time, services must grapple with and overcome a continuing supply-demand mismatch in general practice.
In response, primary care is adopting new approaches to chronic disease management in the form of virtual clinics. This model has been implemented successfully across a number of PCNs and practices with the help of Suvera, a digital specialist in management of chronic conditions.
On average, 70% of patients reach normal blood pressure control within 28 days of using the Suvera service. So it’s no wonder PCN partners are turning to Suvera technology to provide proactive care at scale across their footprint. In this case study, we take a look at just some of the work being done.
Designing a virtual anticipatory care service
Enfield South West PCN and Half Penny Steps Health Centre tasked Suvera with fully managing their hypertension registers. A key aim for both partners was the achievement of normotensive ranges for both HYP 003 and 007 indicators.
Serving overall PCN list sizes of 50,000 and 6,000 respectively, Suvera’s Virtual Clinic combines workforce support, care coordination and delivery in an all-in-one solution designed to help practices and PCNs meet targets on a budget.
At the outset of any partnership project, the Suvera team engages closely with the PCN to understand their ways of working and key goals for the service.
Once this is established, the team gets to work on launch, enrolling target patient cohorts within the virtual clinic and onboarding practices. Practices can be onboarded in as little as two weeks.
Dr Arjuna Yogaskaran, PCN Clinical Director, Enfield South West PCN says, “Suvera were easy to engage with, understanding our needs and ways of working. The induction process was well organised and easy to follow, and they are extremely responsive to any queries.”
Risk stratifying populations
Next, Suvera’s team of data analysts work on case finding and risk stratifying patient lists based on historical clinical data from patient records. The Suvera platform then automates outreach to patients via SMS, and streamlines care coordination.
Unlike other tools, Suvera can also facilitate data collection for multiple conditions in a single touchpoint. Once an individual is enrolled in the clinic, a member of the care team reviews the patient’s information and Suvera technology sets up appropriate, automated sequences of care.
This ensures patients are seen at the right time by the correct clinician for their condition through bespoke clinical pathways. And a dynamic appointment model is in place to cater for any complexities, for example if a patient is also due for review for diabetes or cholesterol.
Supporting patient engagement
Individuals are invited to discuss their treatment goals with follow-up appointments scheduled as appropriate. Suvera clinics offer flexibility for individuals with a hybrid of both virtual appointments and in-person check-ups available.
Dr Earim Chaudry, GP Partner & Clinical Director, Half Penny Steps Health Centre notes, “Patients are well looked after and giving great feedback on their user experience with Suvera and we are achieving better than ever core performance indicator targets.”
Indeed, patients can easily engage with their care through the web app, and submit key health readings from the comfort of home. This empowers patients to take an active role in their care. And real-time remote monitoring enables those who need support to be identified in a timely manner.
Delivering outcomes
The Suvera team is also on hand to provide much needed resource where required across practices, building out multi-disciplinary team expertise. Staffed by clinical pharmacists specialising in management of chronic conditions, the service is entirely focused on optimising LTC outcomes and has made a major impact for both partners. The results?
- Enfield South West PCN finished the financial year with an average 83% target achievement across all practices, surpassing the target of 77%
- Half Penny Steps Health Centre attained an average 85% target achievement, a significant improvement on the previous achievement of 62%
Half Penny Steps Health Centre says:
“I would wholeheartedly recommend the Suvera solution to practices looking for innovative ways to increase clinical capacity and provide better health.”
Dr Earim Chaudry, GP Partner & Clinical Director, Half Penny Steps Health Centre (NWL ICB)
Enfield South West PCN says:
“We are now extending our work with Suvera to cover type 2 diabetic patients and patients with raised cholesterol in high-risk groups/QOF cohorts.”
Dr Arjuna Yogaskaran, PCN Clinical Director, Enfield South West PCN | NCL ICB Digital Lead
References
1. NHS England. Millions more people receive GP appointments compared to before the pandemic. Available online: england.nhs.uk/2024/01/millions-more-people-receive-gp-appointments-compared-to-before-the-pande mic/. Accessed March 2024.
2. The Health Foundation. Rethinking access to general practice: it’s not all about supply. Available online: health.org.uk/publications/long-reads/rethinking-access-to-general-practice-it-s-not-all-about-supply. Accessed March 2024.
3. Williams NH, et al. Br J Gen Pract. 2018 Aug; 68(673): 388–389.
4. NICE. Hypertension in adults: diagnosis and management. Available online: nice.org.uk/guidance/ng136/chapter/Context. Accessed March 2024.