Using data to improve hypertension care and medicines optimisation in Bexley

Clinical Effectiveness South East London

Project summary

This project turned routine hypertension data into targeted medicines optimisation for the Bexley practices whose patients needed it most. Clinical Effectiveness South East London (CESEL) used existing NHS data tools, health informatics and local analysis to identify hypertension as the long-term condition with the greatest unwarranted variation in care and outcomes locally, and to locate where this variation was greatest across Bexley.

CESEL then provided targeted data analysis and support to the five lowest-achieving practices. We gathered and analysed data from local, regional and national sources, converted it into practice-level intelligence, and shared it through data packs and walkthroughs. Crucially, we did not just present data. We helped teams become more data literate: where to find relevant data, how to interpret variation, how to use Ardens searches and dashboards, and how to turn a broad performance problem into a targeted patient list. Data was not used simply to report performance; it directly guided action.

Once patients and gaps were identified, practices were supported with CESEL’s evidence-based South East London hypertension guide, prescribing pathways and hypertension education. This helped teams move from “who needs review?” to “what should we do?” Support included coding and data-quality work, recall improvement, structured follow-up for patients above target, home/ambulatory BP monitoring pathways, clinical education, and bespoke education for non-clinical staff so reception, admin, care coordination and HCA teams could support BP checks, annual review, urgent escalation and follow-up.

Using SEL Business Intelligence Unit data, Bexley hypertension achievement improved between March 2025 and March 2026. Under-80 achievement rose from 64.9% to 75.9%, and over-80 achievement from 79.9% to 85.9%. The five high-support practices started from a lower baseline but showed the greatest improvement: under-80 achievement rose from 54.1% to 70.2%, and over-80 achievement from 73.1% to 81.1%.

Slade Green illustrates the model. It was one of the lower-achieving practices and had previously been hard to engage in quality improvement. CESEL built a trusted relationship over time, including trust in the data being shared, then supported the practice to use available tools and guidance to improve hypertension processes prescribing and outputs.

This work sat alongside wider Bexley improvement activity, including local incentives. CESEL’s distinctive contribution was leading the data analysis, interpretation, practice targeting and hands-on support that helped teams turn existing digital intelligence into better hypertension care and safer, more systematic medicines optimisation.