Improved long-term condition management

Hypertension, or high blood pressure, is often referred to as a 'silent killer', with the British Heart Foundation and Stroke Association attributing around 50% of heart attacks and strokes to hypertension. With its much higher prevalence in ethnic minorities and deprived groups, the NHS' National Healthcare Inequalities Improvement Programme has included hypertension as one of five clinical areas of focus which require accelerated improvement.

The London borough of Lambeth has a deprived and highly diverse population, whose black community has more than double the hypertension rate seen in the white population. Operose Health launched a 12-month programme at two of its practices in the borough to challenge some of the organisational and social factors contributing to this healthcare inequality.

Tackling inequalities in blood pressure control

A 12-month project was initiated at two of Operose Health's practices, Edith Cavell Surgery and Streatham High Practice, to improve overall control of hypertension for all patients – with a particular focus on patients from black African and black Caribbean backgrounds.

The programme was led by a senior GP and primary care network (PCN) manager who organised an approach involving centralised recall and pharmacist teams working alongside practice-based pharmacists and health care assistants (HCAs).

The team used Operose's data analytics platform, EZ Analytics, to identify those most at risk, and monitor real-time progress. Identified patients were contacted directly, and staff with language skills or interpreters helped the programme maximise its reach.
Once contacted, the team arranged for patients to provide a home blood pressure reading or attend the practice or local pharmacy for assessment. If repeated readings gave cause for concern, patients were booked in for an appointment in a dedicated pharmacist clinic to receive guidance and education around self-care and information about lifestyle approaches and medication.

At the start of the project, across the Lambeth PCN, 67% of white and only 55% of black patients aged under 80 with hypertension were being treated, representing a 12% inequality gap. Over the course of the 12 month project, this inequality gap in blood pressure treatment between black and white patients was eradicated. In addition, over 300 patients from the local community were newly diagnosed, and over 2,000 NHS health checks were carried out by the HCA and nursing team in 12 months.

The Lambeth hypertension programme demonstrates the opportunities available in primary care to identify, focus on and address health inequalities in local communities. This benefits the wider health and social care system by reducing the likelihood or acuity of additional treatment, for example, due to the incidence of stroke and heart attack.