At HTN Now, we heard from Dr Jonathan Serjeant, chief medical officer of Generated Health (GH), and Matthew Davis, clinical pharmacist and cardiovascular disease (CVD) implementation lead from Bedfordshire, Luton and Milton Keynes (BLMK) ICB. Jonathan and Matthew joined us to discuss how they have used digital tools to improve population hypertension management for the ICS.
Hypertension in BLMK
Jonathan introduced the session by talking a little bit around hypertension and the BLMK context.
“Matt’s team and our team at Generated Health have been working together over the last 18 months to improve population hypertension management across BLMK. There’s some 7.6 million people living with cardiovascular disease in the UK, and 25 percent could have a premature death, so there’s a really good reason to focus on this.
“At the moment, nationally, we’ve got about 68 percent of people who have hypertension who are treated to target. There’s an ambition to get that to 77 percent by the end of next year, and at the same time there is a focus on secondary prevention for cardiovascular disease. Of about 2.6 million people with recorded cardiovascular disease, currently 82 percent take some form of lipid management or cholesterol management and medicines; but that doesn’t mean they’re treated to target.”
When you look at the difference that can be made by doing this in the average ICS, Jonathan said, the figures show around 11,000 people with diagnosed cases of cardiovascular disease and 60,000 people in every ICS in the country who are not optimised to target. If this can be improved, there is the potential to reduce number of deaths by around 1,550 across a three-year period.
In BLMK, the population covers about a million, with around 47,000 people with uncontrolled hypertension. Jonathan commented that the ICS has been taking “an innovative approach” to tackle this, supporting PCNs and practices to make an impact. In terms of secondary CVD prevention, the ICB is aiming for 35 percent of people to be treated to target.
Bringing Florence to BLMK
Matt took over from Jonathan to explain in more detail about how exactly Florence was identified as a potential solution at BLMK:
“My background was as a cardiovascular and stroke pharmacist within secondary care before I moved to the ICB, so I’ve seen heart attacks and strokes; I’ve seen the effect that has on people, and I think that’s why I’ve moved into CVD prevention. I recognise how much benefit we can get from controlling these factors.
“With hypertension we’re not performing particularly well,” he acknowledged. “When we looked at it last year, we were one of the lowest performing ICBs for hypertension management. I also work within practice, and one of the things I recognised was that we get the same amount of time with somebody who has well-controlled hypertension as we do with a person who actually needs an intervention.”
In addition, as an ICB, Matt noted that they are “struggling to get some of the blood pressure results back from people. I think last year, when we started, we had 25 to 30 percent of people who had not even submitted a blood pressure within the last 12 months.”
As a result, the ICB sought to utilise technology to see how they could increase the number of people submitting blood pressure results, in a way that reduced administration time within the practices. “We wanted a digital solution that would engage patients and then make it easy for the results to be put back into the system,” stated Matt.
“Florence was the tool that came out of our work with AHSNs to locate an appropriate solution. It messages the patient, engages with them, and it also allows them to respond; that means that we could find out why some patients never submitted a blood pressure reading. Is it because they just don’t engage, or do they not have access to a blood pressure monitor? We’ve been able to put these steps in so we can pick out any problems the patients are having and find earlier intervention as well.”
Initially, they started with four practices, utilising some of the medicines optimisation team. “We’ve been able to support them by utilising Florence to find the patients and send out the messages to the patient, and then support the practice to be able to put the blood pressures back into the system,” Matt shared. “Our model is like a hub model that operates across the ICB, working with specific PCNs. Our team started small in terms of the number of practices we could support, and the idea now is utilising some of the PCN staff and practice staff, such as clinical pharmacists who are ideally placed to support this work. We’re now rolling out protocols again across those PCNs and individual GP practices as well.”
Jonathan provided more detail on Florence, an intelligent messaging platform that communicates with patients to encourage them and activate behavioural change, so that they can actively manage their care better. Florence is “as digitally inclusive as it can be,” he said, “because it uses text messaging, and it can be in any language, focusing on one of the key barriers to health inequality which is to ensure that you use the right language.”
Florence has been around for a decade, supporting hypertension management along with other chronic conditions. It is used across different sectors and has been independently evaluated to demonstrate how it can better clinical outcomes.
“We save time and money and improve clinical efficiency,” Jonathan shared. “In terms of its simplicity, it’s just your phone, doesn’t have to be a smartphone. Florence talks to you; it’s intelligent; it’s algorithm-based communication. If you send things in that are a bit concerning to Florence – for example if your blood pressure’s a little bit high, but not an emergency – Florence will reassure you and get you to take it again. Patients can get bite-sized education around hypertension and other long-term conditions, so you can slowly build the confidence and the awareness around people’s illnesses.”
As a clinician, he continued, “you can see all the patients o the platform, which enables you to manage your whole population. You can see the number of people who are using the protocols. You can see people who disengage, so you can think about different ways to engage people in their care. The platform has been built so that it has its best standard protocols that you can use, because we know they deliver particular outcomes, but you can also make it completely bespoke to what you need as a customer to get the maximum benefit.”
Taking diabetes as an example, Jonathan explained that stats have shown that people using Florence have got their HbA1c down from 76 down to 64. It has also been used in maternity units to improve things like breastfeeding, helping facilitate connection so that people don’t feel alone in early pregnancy; and also in asthma, to support people in terms of exacerbations and reduce inpatient admissions.
“We also do stuff around medication adherence and reminders on picking up and taking medication, which leads to improvements in the number of prescriptions issued per month for people for their long term conditions. Critically for us, this shows that changing people’s behaviour allows you to sustain better clinical outcomes.”
Implementation at BLMK
Jonathan and Matt talked us through how the implementation process went with Florence at BLMK.
Jonathan said: “The key with any piece of technology is the teams working together. We started off by trying to identify new hypertensives, and we found that we needed to get it out to a large cohort of people quite quickly. So we developed something called bulk upload. You can put hundreds of people onto the system and then manage those people, and ensure all that information coming back goes directly into the clinical record.”
Matt continued: “We went out to practices around July, to offer them this protocol, and I think we’re up to about 18 practices now that have signed up. We developed two protocols – one will take the patient through the process of initiating medications, and then if the blood pressure comes back normal, the team within admin, who’ve been trained with a pharmacy technician, can just message the result back. We are seeing reduced GP time in not having to do the follow up, because Florence can identify that that person’s BP is in control and therefore we can utilise other members of staff to review it.
“The other one that we’re excited about is the titration protocol, which actually looks for those with a higher blood pressure. We initially offer two medications at the start, then a second one after four weeks if their blood pressure’s on target. When they start the first medication, Florence will check their blood pressure at four weeks. If the blood pressure comes in high, Florence will prompt them to start the second medication. It also checks if they’ve got any problems or any side effects. That will reduce one GP appointment or one clinical pharmacist appointment, where the patient doesn’t have to be seen in clinic. We had about 200 patients who had the new protocol sent out in October, so we’re looking to evaluate it in the next couple of months again, but we are starting to see that those second appointments aren’t having to come back in.”
A particular benefit from working with the Generated Health Team, Matt said, was the fact that they brought their experience of doing this work in other areas, leading to new ways of looking at information or approaches.
“Within the new primary care targets for cholesterol management, there are two areas for improvement within patients with cardiovascular disease. The first one that we’re focusing on is ensuring that everybody is on a cholesterol lowering medication. We’re not doing too badly with that – 15 percent compared to a national average of 17 percent not being on cholesterol lowering medication with CVD – but that still equates to about 3,700 patients across the ICB. Practically, with pressures on primary care, we’re not going to be able to bring 3,700 patients in for a 10-minute review, so we’re utilising Florence to send a message to patients. It will engage them, it will check if they’ve got any history of CVD, it will educate them on it, and then it will offer them either a cholesterol lowering medication or one of the new medications which is not a statin. That allows us to prioritise those people that would like to have a cholesterol lowering medication, which doesn’t take much time for clinicians, because the person’s already got the information. We can then code out the patients who currently don’t want any medication, but it allows us to focus on those perhaps in different ways in the future.”
Jonathan went on to share some of the outcomes and impacts that have been seen at BLMK, including a clinical time saving of 75 percent to dual therapy; that 76 percent of people who start the protocol complete it; and that 90 percent of people report being very satisfied using Florence. Matt added that BLMK has seen a five-to-10 fold reduction in the amount of admin time it has taken to process results which are fed back into the system, since introducing Florence.
Finally, moving on to discuss programmes at BLMK around community identification, Matt said: “We’re working quite closely with public health, particularly in our Luton area – they’re proactively going out to different community groups, to try and do those initial blood pressure screenings, and we’ve also got machines that check everything and identify people with high blood pressure. We’re also trying to increase capacity within the community hypertension case finding service as well.
“One of the problems can be that you find these people within primary care or within community, and you don’t know whether they will go and get further follow-up. Being able to use Florence and give somebody a code that will then log them onto the dashboard – that means we can guarantee the result goes back to the GP clinical system so they can be followed up.”
Looking to the future, he concluded: “Over the next 12 months, we want to increase the numbers of practices that engage, so we’re bringing out packs to identify how practices are performing, and then we will be able to go in and offer the solution. Once we get the cholesterol one working and get the data back from the titration, we can look at other areas where we can engage patients.”
Many thanks to Jonathan and Matt for joining us.