From January 2022 to March 2023, the AHSN Network will deliver a Blood Pressure Optimisation programme in partnership with NHSX, aiming to prevent heart attacks, strokes, and vascular dementia in patients with hypertension.

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 cardiovascular disease. These risk factors are high impact but also highly modifiable.

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.


  • 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

AHSNs will support Primary Care Networks (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 Blood Pressure Optimisation 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 National Lipids and Familial Hypercholesterolaemia programme.

Contact us

If you have any questions about the Blood Pressure Optimisation Programme, please email