Support to manage your practice hypertension targets

5th May 2023

To mark World Hypertension Day on Wednesday 17th May, we caught up with Dr Raj Bethapudi, who discusses the vital role of supporting GP practices to manage their hypertension targets.

Dr Bethapudi is a partner at The Galleries Medical Practice in Washington and co-chair of the North East and North Cumbria Integrated Care Board (NENC ICB) Cardiovascular Prevention Network. Raj has a keen interest in reducing mortality and morbidities associated with cardiovascular disease along with ensuring sustainability of General Practice and the health economy.

In this Q&A, in his role as Regional Clinical Champion for the Blood Pressure Optimisation Programme in the NENC region, Raj highlights why it is more important than ever before to tackle hypertension, and provides some practical tips and suggestions for practices and primary care staff, to help you to meet hypertension targets, including the Quality and Outcomes Framework (QOF).

Why is it important that practices manage and support patients with hypertension, and what is the potential impact on our patients?

As healthcare professionals, we understand the importance of prevention in tackling disease burden and one of the corner stones in reducing cardiovascular mortality and morbidity is early identification and treatment of hypertension.

As QOF targets were suspended for two years due to Covid-19, the percentage of patients treated to target has dropped from 71.6% in 2019/20 to 52.7% in 2020-21, resulting in 300,000 patients who have not been treated to target¹. This has potentially increased risk of approximately 3,800 strokes and heart attacks across a three year period as a result of the suboptimal treatment of hypertension². However, if we increase the percentage of optimised blood pressure to 80% across a three year period, this is going to reduce approximately 519 strokes and heart attacks with an estimated £6 million saved in the North East and North Cumbria as a result³. This clearly underpins the importance of making hypertension identification and treatment everyone’s business to ensure our patients get the best treatment they deserve.

Identification and treatment of hypertension continues to be a key target of both the QOF and PCN IIF, ensuring practices are financially remunerated for the effort they put in at a time when financial sustainability of practices has become a challenge.

What advice would you give to practices to support them to achieve hypertension targets?

Some practical suggestions that can help practices achieve targets might include:

  • Introducing a hypertension champion within your practice – with a clear understanding of the number of patients in your surgery with uncontrolled/non-coded hypertension and the number of new diagnoses of hypertension needed to achieve the PCN IIF targets.
  • Communications and messaging to patients – promoting the know your numbers campaign to encourage patients to take ownership of their blood pressure control, use of patient messaging services, and facilitating contact using GP surgery websites can be tried based on practice and patients’ preference.
  • Encouraging the use of BP monitors at home – in my clinical practice, it was interesting to note the high number of patients who either already had a BP monitor or were happy to buy their own and coding these patients as having a monitor would be helpful to reduce the burden on practice appointments, especially if their BP remains high or their last BP reading in their notes was recorded to be high.
  • Supporting patient self-management – ensuring our patients fully understand the risks of uncontrolled hypertension, their treatment targets and admin staff having a laminated chart of normal and abnormal readings can be helpful.
  • Investing in training – of HCAs, social prescribers, health and wellbeing coaches where they are confidently able to identify raised BPs and issue home blood pressure/ambulatory blood pressure monitors appropriately reduces burden on GP appointments.
  • Support from other primary care services – having a good understanding of local pharmacies signed up to the hypertension diagnosis initiative and signposting opportunistically, having BP pods in practice waiting areas, and investing in BP monitors can also help alleviate pressure on GP appointments. Consider speaking with your PCN Clinical Director to see if some of these measures can be funded using PCN development funds.

If some or all of these measures can be implemented in primary care, we will be in a good position to reduce health inequalities and tackle cardiovascular disease.

How can the AHSN NENC support practices?

The AHSN NENC is working across the region to support practices to implement the new UCLP Proactive Care Framework for hypertension.  The framework will help practice and PCN staff to prioritise in this challenging time and focus resources on optimising care for patients at the highest risk. It will support the use of the wider workforce to deliver high quality proactive care, improved support for personalised care and aims to help release GP time.

To further help practice staff to deliver targets, the AHSN NENC delivered hypertension educational webinars for primary care last year outlining the support on offer and an introduction to the proactive care framework for hypertension. Watch the recording here.

Contact Karen Verrill, Programme Manager, to find out more about how the AHSN NENC can support you with hypertension targets.


  1. Public Health England and NHS England 2017  Size of the Prize.
  2. Royal College of Physicians (2016). Sentinel Stroke National Audit Programme. Cost and Cost-effectiveness analysis.
  3. UCLPartners 2022  Size of the Prize, North East and North Cumbria.