The West of England AHSN are delivering a blood pressure optimisation programme in partnership with NHSX, aiming to prevent heart attacks, strokes, and vascular dementia in patients with hypertension.

As part of this new programme, we are supporting Primary Care Networks (PCNs) to implement a UCLPartner-developed care framework for hypertension, which aims to optimise clinical care and self-management.

The challenge

Cardiovascular Disease (CVD) is a leading cause of premature mortality and morbidity in England. The Global Burden of Disease Study identified high blood pressure and high cholesterol as leading risk factors that drive mortality and morbidity from CVD. These risk factors are high impact but also highly modifiable. Read more about our work on CVD.

Treatment of high blood pressure and high cholesterol substantially lower the risk of CVD. Despite this, both risk factors are underdiagnosed and undertreated. Around 30% of people with hypertension are unaware of their condition, and the pre-pandemic Quality and Outcomes Framework (QOF) data showed that around one third of people with diagnosed hypertension are not treated to QOF target, with substantial variation across the country.

Prevention of CVD in people with hypertension requires optimal control of both blood pressure and cholesterol. Around 50% of people with established CVD also have hypertension. All men over the age of 55 with hypertension and women over the age of 60 with hypertension who do not have CVD are nevertheless at high risk (with a QRisk score above 10%). These individuals should be offered treatment with lipid lowering therapy, but large numbers are either on no treatment or suboptimal treatment.

Blog: Doing things differently

The AHSN Network have published a blog by Dr Matt Kearney, GP and national lead for the blood pressure optimisation programme and UCLPartners Programme Director for CVD Prevention and Proactive Care.

Read Matt’s blog to find out how we’re working across the Network to prevent heart attacks and strokes at scale.

Programme objectives

  • Improve blood pressure and broader cardiovascular disease risk management (especially lipid management) in people with hypertension.
  • Improve management of cardiovascular disease risk factors reduced heart attacks, strokes and cases of vascular dementia.

Our approach

We will support PCNs to implement the UCLPartners Proactive Care Framework for hypertension, to optimise clinical care and self-management of people with hypertension. This will be achieved through:

  • Risk stratification to prioritise which patients to see first
  • Use of the wider workforce to support remote care and self-care
  • Supporting systems to adapt the framework pathways for local implementation
  • Supporting patients to maximise the benefits of remote monitoring and virtual consultations where appropriate.

We will also support PCNs to increase the detection of people with hypertension through case finding interventions (including practice case finding through patient record searches, and models that involve community pharmacists as part of the new hypertension community pharmacy scheme). We will support Integrated Care Systems to reduce health inequalities by targeting 20% of the most deprived populations and other local priority groups (applying the Core20PLUS5 framework).

The programme supports systems to take a multi-morbidity approach in supporting patients which hypertension. This approach will enable AHSNs to deliver on the objectives of both the NHS England @home programme and AHSN Network’s Lipids and Familial Hypercholesterolaemia programme.

ICS blood pressure data

UCLPartners has launched ‘Size of the Prize’ blood pressure data. For each ICS and region in England, this resource shows on a single slide:

  • The impact of COVID: in disrupting treatment for people with hypertension. On average the proportion with optimally controlled blood pressure has fallen from 70% to under 50%.
  • The risk: how many strokes and heart attacks might result if that disruption is not rapidly corrected. Across England this number exceeds 27,000 in three years.
  • The ambition: how many additional heart attacks and strokes can be prevented in three years and what savings can be generated if more people have their treatment optimised – with three levels of ambition.

Get involved

If you have any questions about the blood pressure optimisation programme or would like to get involved, please contact us.

You can find details of our events for health and care providers, including coaching workshops for those involved in this programme, on our events listings.

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