Case Study: Emma Debbage, Practice Manager at West Street Surgery
The introduction of Florence at West Street Surgery has transformed Practice Manager, Emma Debbage and her team’s management of their hypertensive population, enabling them to reach previously disengaged patients and focus on those most in need of intervention, maintain their high QoF scores, and all while alleviating the administrative burden on GPs.
- After five years of efforts to collect readings from these patients, 32% of those who were previously disengaged submitted at least one blood pressure reading via Florence
- West Street Surgery now has 92.9% of patients over 45 with a submitted a BP reading in the preceding 5 years (QoF BP002 benchmark is 90%) (only 401 patients left to engage)
- 81.4% of hypertensive patients are now in range surpassing the required 77% threshold.
- Blood pressure monitoring rates for coronary heart disease, stroke, and diabetic patients also significantly exceeded QoF targets.
At West Street Surgery in Central Bedfordshire, Practice Manager Emma Debbage has spent the last five years relentlessly improving patient engagement and data collection for hypertension management. Despite her team’s best efforts, there was one cohort of patients she was unable to connect with. She had to find a way to collect consistent blood pressure (BP) readings from patients while alleviating the administrative burden on GPs.
This is where Florence, the AI-powered smart messaging system, has changed the game.
The Challenge: Managing Hypertension at Scale
Over the previous five years, Emma and her team had been working hard to ensure their Quality and Outcomes Framework (QoF) scores for blood pressure monitoring remained high. By April 1st each year, they aimed to have all necessary patient data collected, so reducing the time GPs spent processing and reviewing blood pressure readings.
Before Florence, this meant constant reminders, phone calls, and chasing patients manually.
Despite their rigorous approach, too high a percentage of patients remained disengaged, and the pressure on clinicians to follow up was mounting. With a higher than national average prevalence of hypertension, and thousands of patients on the hypertension register, including those with coronary heart disease, transient ischemic attacks (TIAs), and diabetes, the workload was immense. Emma knew that a new approach was needed—one that leveraged automation while keeping patients engaged.
Introducing Florence: A Smarter Way to Engage Patients
Whilst AccuRx was in place to collect BP readings, there was no structured way to monitor responses and escalate cases efficiently, the process had limitations.
With the introduction of Florence however, West Street Surgery, could send automated reminders to patients, track their responses, and filter out those patients who had already provided acceptable readings. It empowered the team to focus on any barriers to patient engagement including access to a BP monitor, and those patients who truly needed intervention, such as those with consistently high BP levels.
The Results: Improved Efficiency and Patient Engagement
The team was “chuffed to bits” by the response they received having identified 688 of the most unresponsive patients or who had readings that required follow-up.
- 225 patients provided at least one BP reading, having not responded before, with many sending multiple readings over time giving the team a fuller picture of the patient health.
- 92.9% of patients recorded BP readings in the preceding five years, against the 90% threshold.
- For hypertensive patients, compliance reached 81.4%, surpassing the required 77% threshold.
- Blood pressure monitoring rates for coronary heart disease, stroke, and diabetic patients also significantly exceeded QoF targets.
The Key to Success: Automation and Human Oversight
Florence automated much of the process, but in partnership with clinicians the team were able to create a truly effective and efficient system for managing their hypertensive population. Florence’s protocols were refined to meet the needs of the local population, ensuring patients received the right level of support without feeling overwhelmed. Emma collaborated closely with her practice’s pharmacists—particularly two prescribers specialising in hypertension—who managed medication adjustments and follow-ups, allowing GPs to stay focused on broader patient care.
Key Drivers to Success Other Practices Can Adopt
With Florence firmly embedded in their workflow, West Street Surgery has a sustainable model for long-term BP monitoring, which they can expand, re-enrolling patients each April, to ensure QoF targets remain on track and hypertensive patients receive the best care possible.
Emma credits the success of Florence at West Street Surgery to three key factors:
- Patient Education and Engagement – Increased participation was achieved by highlighting Florence as an innovative service for patients rather than just another routine request.
- Commitment to Data-Driven Decision Making – Continued improvement was ensured by closely monitoring patient response rates and adjusting protocols accordingly.
- Empowering Pharmacists – Streamlined patient care was achieved by shifting the burden of BP monitoring to a dedicated team of prescribing pharmacists.
Looking Ahead: A New Standard for Hypertension Monitoring
For other practice managers looking to improve BP monitoring and patient engagement, Emma’s advice is clear: dedicate time to implementing Florence, structure your team efficiently, and ensure clear communication with patients. The results speak for themselves.
West Street Surgery has proven that with the right blend of automation, human oversight, and patient engagement, hypertension monitoring can be transformed—saving time for clinicians and improving health outcomes for patients.
Contact the team at Generated Health
John Griffiths john.griffiths@generatedhealth.com
Kylie Dentith kyliedentith@generatedhealth.com
Dave Armitage dave.armitage@generatedhealth.com
