South West AHSN and innovative Devon GP practice spread new ways to tackle blood pressure

The South West Academic Health Science Network is working with a GP practice in Devon to spread new ways of identifying and treating people with high blood pressure across the South West – where hypertension is higher than the national average.   

Okehampton Medical Centre has increased blood pressure detection and management rates by an average of 25%, potentially saving up to six strokes and four heart attacks among patients, thanks to its innovative approach to blood pressure optimisation involving adapting an innovative proactive care framework, teamworking and supporting self-management.   

Following its success, the South West AHSN has partnered with Okehampton Medical Centre to support primary care across Somerset, Devon, Cornwall and the Isles of Scilly to similarly optimise care for people with high blood pressure.  

The work, involving peer-to-peer mentorship, is part of our national blood pressure optimisation programme and has significantly facilitated the adoption and spread of best practice in tackling high blood pressure in over 20 Primary Care Networks and GP practices to date. 

Championing cardiovascular disease care in Okehampton 

Throughout South West England, prevalence of hypertension is higher than the national average (16-17% compared to 13%), with rural and coastal areas being particularly affected.  

Historically, BP patients were mostly managed through face-to-face consultations, which meant extra time spent for patients and doctors and measurements being taken in an unfamiliar environment, potentially influencing the result.​  

Rather than recruiting more staff, which is particularly challenging in the South West with higher vacancies rates than the national average (Care Quality Commission, 2022), Okehampton Medical Centre set out to tackle hypertension differently. 

Their approach involved adopting the UCLPartners Proactive Care Framework for hypertension providing search and risk stratification tools, workforce education and training, and digital resources to support self-management.  

All patients are educated about the target range for blood pressure and its importance, signposted to monitoring resources, and encouraged to self-monitor their blood pressure at home.  

Okehampton’s receptionist, audit and IT teams work together using digital platforms to collect readings, communicate and follow-up with patients. Their health care assistants or junior nurses gather information about BP, weight, pulse and other long-term condition indicators. They also support patients with self-management and lifestyle changes.  

Long term conditions non-medical prescribing nurses and pharmacists manage all patients’ risk factors, treatments and escalate or de-escalate interventions. GPs are involved only in exceptional circumstances related to high-risk patients. 

As a result, Okehampton Medical Centre has increased BP detection and management rates by an average of 25% with further increase expected as this new way of working becomes business as usual.   

The practice has also seen a significant reduction of GP workload in managing blood pressure, where only a fraction of high-risk patients have been escalated to the GP.   

The practice team and patients have grown in confidence by feeling empowered to manage blood pressure and associated risk factors.   

Collaborating to spread innovative practice  

As part of our national blood pressure optimisation programme, the South West AHSN has catalysed the spread and adoption of Okehampton’s approach to blood pressure optimisation by facilitating peer-to-peer mentorship between Okehampton Medical Centre and fellow GP practices across the South West, particularly those within deprived rural and coastal communities. 

Together we spread best practice through our region via a series of collaborative and peer-led CVD workshops throughout 2022, to support practices and Primary Care Networks to implement the UCLPartners Framework and consider Okehampton Medical Centre’s adaptation of the framework to blood pressure management and how they may emulate processes in their own practices.  

This bespoke targeted support has significantly facilitated the adoption and spread of best practices and new ways of tackling high blood pressure in over 20 Primary Care Networks and GP practices so far. 

Next steps  

The national blood pressure optimisation programme ran until March 2023. Despite its closure, the South West AHSN is continuing to capture more insights from staff and patients and analyse regional CVDPrevent data to track impact.  

Building on the spread and adoption momentum, the South West AHSN, in collaboration with local Integrated Care Boards and training hubs, plans to develop a package of regional CVDPrevent workforce training that will be offered to all primary care staff. 

To learn more about our work to support primary care to optimise blood pressure detection and management please visit our webpage.