A team at a South London primary care network has eradicated a large gap in blood pressure control between white patients and those from a Black or minority ethnic background, after a year-long project.

AT Medics Streatham PCN in Lambeth found that among their patients under 80 diagnosed with hypertension, there was a 12% inequality gap in blood pressure control, with 67% of white patients and 55% of black patients treated to target.

Since Covid, the data has shown hypertension outcomes have fallen while inequalities have grown, the team said.

The two practices in the PCN have 45,000 patients, with around 3,100 diagnosed with hypertension. They set up a centralised recall system and made use of practice pharmacists and healthcare assistants to provide guidance, education around self-care, lifestyle and medicines.

At the end of the year-long project, 98% of hypertensive patients were recalled and had a blood pressure reading in the 12-month period and by the end of the year 87% of all patients under 80 years were controlled, the study showed.

For white patients this was 86.9% and for black patients, 87.4%. Overall the PCN has achieved 20% better control than the next best PCN in Lambeth.

The team has also identified 300 newly diagnosed patients through the project in the past year.

As part of the study, patients were contacted by text, email, phone calls and letters if necessary, and staff with language skills and interpreters helped reach out to patients who could not speak English.

Patients were asked to provide a home blood pressure reading or attend the practice or local pharmacy for a blood pressure assessment. They were also proactively offered health advice and opportunistic blood testing for lipid levels, Hba1c and renal function.

If repeated blood pressure measures were out of range, patients were booked in for an appointment in the PCN's dedicated pharmacist clinic, either on the telephone or face to face.

Results from the programme have been shared with the NHS England Board as part of the National Healthcare Inequalities Improvement Programme.

Yvette Agyako, lead pharmacist on the project said that the pharmacists within the team had 'thoroughly enjoyed being part of this project'.

'We often see patients with hypertension but do not usually have the opportunity to see outcomes as good as we have seen this year. Being part of this project has meant not only were we able to apply our skills and knowledge, but we were also able to feel we were making a real difference to patients.'

She added: 'The support that we have as a team is very important and we can go to anyone for help. The way in which we have been able to support patients is why we do our jobs. It is important that our patients know that we are here for them.'

And Dr Tarek Radwan, GP director, said that the 'incredible results' delivered by the project were 'all down to the dedication of our amazing team, especially our administrators, healthcare assistants and pharmacists'.

He added: 'The last 12 months have proved that we can not 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.'

Dr Selvaseelan Selvarajah, GP partner at the Bromley-By-Bow Health Centre in Tower Hamlets, East London said the approach of using the wider healthcare team to identify and manage hypertension is something that has also been working well for them.

In his practice, patients have also been advised to buy their own BP machine and were given guidance on how to use it.

‘If they are unable to, they can use the BP pod in our reception or are booked with a healthcare assistant. Patients are taught to self-manage and take charge of their BP control,' said Dr Selvarajah.

‘This has been very welcome and progressive. I think it is crucial we facilitate patients to manage their own health and empower them to make the necessary changes.’

A version of this article first appeared on our sister publication, Pulse.