Overview of the programme

Heart attacks, stroke and other forms of cardiovascular disease (CVD) result in a quarter of all deaths in the UK. They are also a major driver of health inequalities, responsible for a large percentage of the life expectancy gap between deprived and affluent communities (source: UK HSA).

High blood pressure and high cholesterol are leading risk factors for CVD, but they are highly modifiable, and treatment substantially lowers the risk of CVD (source: British Heart Foundation).

Regional AHSNs are working to lower these CVD risk factors through our Blood Pressure Optimisation (BPO) programme, supporting primary care in three ways:

1. Implement UCLPartners’ Proactive Care Frameworks

Proactive Care Frameworks support primary care staff within Primary Care Networks (PCNs) to optimise clinical care and self-management for people with high blood pressure and other CVD risk factors such as high cholesterol. The Frameworks offer:

  • Risk stratification to prioritise which patients to see first
  • Use of the wider workforce to support remote care and self-care
  • Supporting patients to maximise the benefits of remote monitoring and virtual consultations where appropriate

These initiatives support GP practices to meet the Quality and Outcomes Framework (QOF) and other quality improvement targets.

2. Develop case finding initiatives

AHSNs are supporting PCNs to identify patients with previously undiagnosed high blood pressure through case finding interventions.

3. Focus on tackling health inequalities

AHSNs are supporting Integrated Care Systems (ICSs) to reduce health inequalities by targeting support to the most deprived populations and other local priority groups for CVD, as outlined in NHS England’s Core20PLUS5 guidance.

Summary of resources

Below, you will find information collated to help you learn more about this programme’s aims, impact, and wider context, including evidence and information to support your implementation.

The resources have been selected for the benefit of health and care professionals. Some information links out to third party sources, and the Health Innovation Network is not responsible for the content on those sites.

CVD costs the NHS an estimated £9 billion a year. Its cost to the UK economy, including premature death, disability and informal costs, is estimated to be an even larger £19 billion per year. (Source: UK HSA)

At the same time, CVD is preventable. Not only through change of behaviour or lifestyle, but also by optimising treatment in high-risk conditions such as high blood pressure, atrial fibrillation and high cholesterol.

Despite this, high blood pressure and cholesterol are underdiagnosed and undertreated. Around 30% of people with high blood pressure are not aware they have it. For those that are diagnosed, pre-pandemic QOF data showed that around a third of people are not treated to QOF targets, and there is substantial variation across the country.

Size of the Prize is a resource developed by UCLPartners. It shows that for every ICS in England, there is potential for preventing heart attacks and stroke at scale and pace by optimising the management of high blood pressure.

Size of the Prize calculations show that if we improved treatment in one London ICS – so that 90% of people with CVD were prescribed a statin and 70% were put onto an optimal dose – this could potentially prevent over 800 strokes and heart attacks in five years. This would save many lives, reduce admissions to hospital, and release resources to be spent elsewhere.

Our Blood Pressure Optimisation programme is led by one regional AHSN, UCLPartners, on behalf of the AHSN Network. It develops all programme information and resources and facilitates learning and collaboration across all 15 AHSNs.

UCLPartners Proactive Care Framework Implementation Workbook

The workbook is a great place to start if you’re exploring the Frameworks for the first time. The workbook covers four modules that support primary care staff to systematically implement the Frameworks within their teams.

Each module takes approximately one hour to complete and contains videos, case studies and opportunities to reflect on your own practices and challenges can be discussed with peers via the FutureNHS Collaboration Platform.

The modules cover:

  • What the Frameworks are
  • Risk stratification
  • Team roles
  • Taking a quality improvement approach

UCLPartners has established a network for clinicians who are supporting the national Blood Pressure Optimisation programme and have a passion for CVD prevention across England.

To find out more or join the network, contact: Primary.Care@UCLPartners.com

Jump straight to a resource of your choice on the UCLPartners Proactive Care Framework website. Resources include risk stratification searches, FAQs and case studies.

Several key policy papers set the context for the work needed to deliver effective services for people with cardiovascular disease:

NHS England has compiled a list of resources to support patients with home blood pressure monitoring. The list includes resources from the British Heart Foundation, Blood Pressure UK and UCLPartners.

For the latest news and opportunities on the national Blood Pressure Optimisation programme, sign up to UCLPartners’ Proactive Care Newsletter.

National enquiry

To find out more about any of our national programmes, please complete this form.

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