Hypertension and Health Inequalities Collaboration in Primary Care (2025)

Deans and Central Brighton PCN & East and Central Brighton PCN

Project summary

NHS England Health Inequalities funding enabled two PCNs to work as a neighbourhood in reducing health inequalities around hypertension and CVD prevention. The design was supported by local ICB clinical leads, together with PCN pharmacists. An additional partnership was with a local VCSE organisation and their local community links. Community support and outreach, and engagement via the VCSE partner (Trust for Developing Communities (TDC) ) led to new ways of reaching patients less engaged with health and social care. The project provided specific hypertension clinics, bp monitoring, information, and sign-posting in the community, and confidence and relationship-building within the VSCE and local community. The project focused on populations with higher proportions IMD1, plus middle aged, ethnically diverse, LGBT+, and homeless people.
The work was supported by PCN managers, engagement workers, data analysist, and a project officer. Data-driven searches were used to identify patients at risk or with suboptimal control, with a particular focus on areas of deprivation and health inequality groups. Structured pharmacist-led clinics optimised antihypertensive therapy, improved CVD risk management, and supported accurate coding, working together with the project officer, who contacted patients directly, obtaining bp readings and booking hypertension reviews.
TDC carried out specific events and engagement with other, smaller, community groups, including homeless support groups, local BAME groups, older people’s lunch groups, and local LGBT+ groups. The team worked collaboratively with GPs and into community locations to embed sustainable processes.
The project reduced unwarranted variation in care, and demonstrated the impact of a pharmacist-led model on tackling health inequalities in cardiovascular care. Demonstrable improvements in clinical outcomes, health equity, and system collaboration across the two PCNs. Quantitatively, blood pressure recording rose by 1.96% overall, across the two PCNs. Treated-to-target (TTT) hypertension outcomes improved by 2.9%. Lipid-lowering therapy (LLT) prescribing rose by 6.62% overall. Patient feedback was overwhelmingly positive, particularly around increased understanding of their condition and the accessibility of pharmacist-led reviews.
The project team was able to develop collaboration within each PCN, across the two PCNs and with VCSE partners, making this a new way and scope of working within the PCNs and for staff supporting the project. Learning from PCN and VCSE staff, as well as positive feedback from patients led to training, learning, and recommendations for future projects, especially the need for communication and aligned pathways, building relationships, and the importance of support from local community / VSCE groups. It has demonstrated how partners can work together to deliver health outcomes, aligned with neighbourhood focus.