Reimagining hypertension management: lessons from Lewisham

Across the UK, millions of people live with high blood pressure that remains undiagnosed, untreated or poorly controlled. In south east London, where health inequalities are deeply embedded, the consequences are even more stark. Hypertension is not just a clinical concern, it is a major driver of preventable strokes, heart attacks and early death.

In Lewisham, this reality was particularly urgent. Nearly 70% of patients with hypertension belonged to the Core20PLUS5 cohort, yet only 55.12% had their condition under control as of 2023 – far below the national target of 77%.

This was more than a gap in care. It was a signal that traditional approaches were no longer enough. Tackling this challenge required new thinking, smarter tools and a clear focus on reaching the people too often left behind.

A new partnership for change

In response to the challenges faced in Lewisham, SEL ICB partnered with Suvera to pilot a proactive, digital model for hypertension care.

Suvera is a digital-first clinic that works alongside NHS primary care to support the management of long-term conditions. Suvera’s service combines digital tools, remote clinical teams and evidence-based care pathways to deliver personalised support at scale. Designed to integrate seamlessly with existing practice systems, Suvera helps reach patients who may not engage with traditional services, whilst also reducing the workload on GP teams.

Together with SEL ICB, Suvera aimed to improve blood pressure control across two Primary Care Networks in Lewisham, with a focus on improving outcomes and reducing health inequalities.

What we did: a virtual, inclusive model of care

The pilot was delivered in partnership with Modality Lewisham and Lewisham Care Partnership, and focused on engaging patients with untreated or sub-optimally managed hypertension.

Using the UCLPartners Proactive Care Framework, Suvera identified and stratified patients based on clinical risk and treatment history. Those with uncontrolled blood pressure were invited to join a virtual hypertension clinic, accessible via app or phone depending on patient preference.

Once enrolled, patients submitted home blood pressure readings and received ongoing support from Suvera’s remote team of clinical pharmacists. Where needed, medication was reviewed and adjusted, and lifestyle support was offered to help patients better understand and manage their condition.

This model was designed to be inclusive from the start. Patients were offered flexible ways to engage, from SMS or letter communications, to equipment and support provided where needed to reduce barriers to participation. Clinical workflows were streamlined using Suvera’s platform, enabling fast, safe and efficient delivery of care without overburdening practice teams.

The results: what changed in Lewisham?

The outcomes of the pilot showed:

• 80.8% engagement rate from the Core20PLUS5 population;
• Average systolic blood pressure reduction of 10.3 mmHg;
• 70.3% of patients who submitted readings achieved blood pressure control;
• Average time to control was just 16.4 days from initial contact;

This model enabled faster and broader engagement than traditional in-person care and reached patients who might otherwise have been missed. More importantly, it demonstrated that virtual services could improve outcomes without compromising on quality, continuity or personalised support.

What you can do: practical steps for primary care teams

For primary care leaders looking to replicate this success, there are some clear lessons from Lewisham:

1. Use your data intelligently
   Start by identifying the patients most at risk using local hypertension registers and the UCLPartners framework. Focus efforts on the populations least likely to access traditional care.
2. Make virtual an option
   Digital services can be inclusive, scalable and clinically effective. Offering multiple engagement options ensures accessibility for all patients.
3. Empower your pharmacists
   Clinical pharmacists are well positioned to lead hypertension management when supported with the right tools and oversight. Investing in their training and embedding them into care pathways can deliver measurable benefits.
4. Design for inclusivity
   Ensure communications, service design and technology are accessible to patients from all backgrounds. 
5. Evaluate and adapt
   Tracking outcomes and patient feedback allows for continuous improvement. Focus on measurable impact, both in clinical terms and in reducing variation across patient groups.

Exploring funding opportunities

There are a range of funding routes available to support innovation in long-term condition management. These can help unlock capacity, enable local pilots and drive impact at scale.

Options include:

• Population health and inequalities funding, with a focus on CORE20PLUS5 groups and aligned system objectives such as CVD Prevent;

• Test and Learn for Neighbourhoods, supporting local piloting and evaluation within integrated neighbourhood teams;

• Digital transformation funding for tools that support recall, segmentation and remote care;

• Public health investment, particularly in proactive case finding, outreach and prevention;

• Life sciences partnerships, to expand access and capacity through sponsored clinic models;

Final reflections

The Lewisham pilot demonstrated that hypertension can be managed more effectively when care is proactive, inclusive and digitally enabled. By adopting a virtual model, more patients were supported, practice capacity was protected, and progress was made in addressing long-standing health inequalities.

At Suvera, we remain committed to working in partnership with the NHS to scale this approach across more communities. If you’re looking to improve long-term condition management in your area, we’d be glad to explore how we can support your goals.

Click here to read the full report.

Let’s build a more proactive, equitable future for primary care – together.