Black and minority ethnic patients with high blood pressure have benefited from a project which was run by two Lambeth GP practices. The project aimed to reduce the very significant difference in blood pressure control (hypertension) between Black and minority ethnic patients and white patients.

The year-long project resulted in the two practices achieving some of the best outcomes ever seen in South East London for overall hypertension control, with a 12% inequality gap for blood pressure control between black and white patients completely eradicated. In addition, over 300 patients from the local community were newly diagnosed with hypertension.

It is well known that nationally, blood pressure control amongst black African and black Caribbean community members is significantly lower than for white patients. This project aimed to directly challenge the factors which contribute to this inequality, including access to healthcare and proactive engagement by the NHS, and to test the impact of a multidisciplinary data-driven approach. Hypertension was chosen due to its wide prevalence, the serious health impact of the condition, the inequalities in treatment nationally and the negative impact on its management following the COVID-19 pandemic.

In the AT Medics Streatham Primary Care Network (PCN) in Lambeth, two of the practices – Edith Cavell Surgery and Streatham High Practice – have a combined patient list of 45,000; of which 3,100 were identified as suffering with hypertension.

At the start of the project, 61% of all patients aged under 80 were controlled, and 77% of all patients aged over 80 were controlled.

From the outset, the ambition was to deliver the best hypertension outcomes in South East London for all members of the communities cared for, and without any additional investment, to prove that inequalities can be tackled sustainably and at scale. The team was committed to significantly reducing the inequality gap between black African, black Caribbean and white patients with hypertension.

At the start of the project, across the Lambeth primary care network, 67% of white and only 55% of black patients aged under 80 with hypertension were being treated to target. This represented a 12% inequality gap. The benchmark data, progress and success were measured through EZ Analytics, an in-house population health management data platform.

When looking at ways in which patients could be helped to gain better control of their hypertension, it became clear the project team would have to directly challenge some of the organisational and social factors that contribute to healthcare inequality amongst members of the Black and minority ethnic communities.

The programme was led by a senior GP and PCN manager who organised an approach involving centralised recall and pharmacist teams working alongside practice-based pharmacists and health care assistants (HCAs). Each member of the team had specific tasks, using a range of methods to contact eligible patients, providing guidance and education around self-care, and providing information about lifestyle approaches and medication. The emphasis on contacting and connecting with black patients was supported by the diversity of the project team, many of whom also had lived experience of issues relating to hypertension and cardiovascular disease.

The programme team was encouraged to maximise their delegated autonomy to shape the programme on the ground. This allowed the admin staff-based recall team and HCAs in particular to play a leading role in driving the success of the programme, by encouraging a flexible approach as the programme progressed.

The team used their data analytics platform which incorporates thousands of key performance datasets from all their clinical systems, to identify those patients most at risk, and to monitor progress on a real time basis.

The programme had several key elements:

• All staff were fully trained and confident in their roles.
• Text, email and phone calls were used to reach identified patients.
• Staff with language skills or interpreters helped reach patients unable to converse in English.
• Letters were sent by post if the team was unable to make contact by phone on different days and times of the week.
• Once contacted, the team would arrange for the patient to provide a home blood pressure reading, attend the practice or visit their local pharmacy for their blood pressure assessment with the health care assistants.
• Proactive health promotion and opportunistic blood testing were offered for lipid levels, Hba1c, and renal function.
• If repeated blood pressure measures were out of range, patients were booked for a face-to-face or telephone appointment in the dedicated pharmacist clinic.
• Maximised recall of patients, especially those with serious mental illness, due for NHS health checks to increase case detection of hypertension, risk of cardiovascular disease, diabetes and chronic kidney disease.

The results of the project show that all patients across the two practices have benefited from the focus on better hypertension (blood pressure) control, and show that 87% of all patients aged under 80 are now controlled compared to 61% a year earlier and 95% of all patients aged 80 or more are now controlled compared to 77% a year earlier.

This means that overall the PCN has 20% better control than the next best PCN in Lambeth for hypertensive patients who are under 80 years old. Despite the high levels of deprivation in the communities that the practices serve, their patients now have the best blood pressure outcomes of any PCN in South East London.

Dr Tarek Radwan, GP Director, said: “This project has delivered incredible results, and this is all down to the dedication of our amazing team, especially our administrators, healthcare assistants, and pharmacists. The last 12 months have proven that we cannot just reduce, but actually eradicate health inequalities, and raise the quality of care for everyone at the same time. I know the difference this will make to our local communities, and it really shows what is possible with a highly motivated multidisciplinary team”.

Michelle Dalmacio, Associate Director for London, Stroke Association said: “It’s brilliant to see such fantastic results from this 12-month programme, which shows that using tailored approaches to access healthcare can improve the overall diagnosis of high blood pressure and help close the inequality gap in its treatment”.