GP Contract Primary Care Networks

How to deliver the Network DES CVD diagnosis and prevention service

GP cardiovascular lead and PCN clinical director Dr Hannah Morgan offers her tips on how to deliver the first phase of the Network Contract DES Cardiovascular disease diagnosis and prevention service

NHS England announced in August this year that the next set of Network Contract DES services would be phased in gradually over 18 months, rather than implemented in full from October as previously planned.

This means that from October Primary Care Networks (PCNs) are beginning work on two services – the Cardiovascular Disease (CVD) diagnosis and prevention service, and the Tackling neighbourhood health inequalities service.

The CVD diagnosis and prevention service element focuses initially on hypertension case finding and improving rates of blood pressure (BP) measurement in the community.

More specifically practices are expected to:

  • Improve hypertension diagnosis, in line with NICE guidance NG136, by carrying out appropriate follow-up of patients who have had a previous BP of ≥140/90mmHg in a GP practice, or ≥135/85 in a community setting. 
  • Undertake activity to improve coverage of BP checks, by: increasing opportunistic BP testing; undertaking BP testing at suitable outreach venues, along with local partners; and working pro-actively with community pharmacies to improve access to BP checks, in line with the NHS community pharmacy hypertension case finding service.

Here are my top tips for supporting Network practices to work together to deliver on the service requirements effectively and efficiently.

1. Explain the ‘why’ to build shared purpose across your PCN

Although contract obligations are vital, they are not what drive us. At a time when primary care is already overloaded and exhausted, it is critical we vocalise why we are prioritising any work. Being clear on our ‘why’ will help to build motivation and enable us to prioritise it and build capacity. It is also what we need to get over to our communities, so they also prioritise this and help us achieve our aims.

Some key points to convey:

  • Cardiovascular disease (CVD) causes a quarter of all deaths in the UK and is the largest cause of premature mortality in deprived areas. This is the single biggest area where the NHS can save lives over the next 10 years.[1]
  • Early detection and treatment of CVD can help patients live longer, healthier lives. Too many people are still living with undetected, high-risk conditions such as high blood pressure, raised cholesterol, and atrial fibrillation (AF). Other countries have made more progress on identification and diagnosis working towards people routinely knowing their ‘ABC’ (AF, BP and Cholesterol). Replicating this approach will be increasingly possible with digital technology, and major progress could be achieved working with the voluntary sector, employers, the public sector and NHS staff themselves.[2]
  • Due to the impact of the Covid-19 pandemic on activity, the majority of QOF indicators were income protected (ie, payments were made to practices irrespective of activity recorded for indicators in 2020-21), to enable practices to direct resources towards the Covid-19 response and targeting care at the most vulnerable and high-need groups.[3] There is likely to a lot of work needed to recover our position on hypertension. Around 30% of men and 25% of women have hypertension and yet it is untreated in 14% of men and 11% of women; of those diagnosed, 67% of people under 80 were treated to target in 2019/20.[4] For a proportion of these patients, control will have slipped during the pandemic and we will need to treat them to target. It is vital we do this work well, and quickly, in order to prevent myocardial infarctions and strokes. This is also crucial for our elective care recovery and social care budgets.

2. Align with other work that is already being done, or that needs to be done this year

[email protected] is a national workstream, so most PCNs will already know about this, as practices are all receiving new centrally funded BP machines, to lend or give to patients. Home blood pressure monitoring has been identified as a priority for CVD management as the NHS recovers from the Covid-19 pandemic to ensure that patients can manage their hypertension well and remotely, reducing the need to attend GP appointments.[5] Find out about this programme in your area, what resources have been developed to support it, what your practices are already doing and what they need support with.

The Impact and Investment Fund (IIF) for PCNs from October this year also aligns. Indicator CVD-01 encourages PCNs to follow up more patients with an elevated BP reading (including through proactive outreach, where possible) to assess them for hypertension, typically through provision of ambulatory or home BP monitoring. CVD-02 rewards PCNs for the corresponding rate of hypertension diagnoses which can be expected having undertaken appropriate follow up activity for individuals with high BP.[6]

Each PCN has to also deliver the first part of the Tackling neighbourhood inequalities service in 21/22. It is a quick win to focus this work on CVD and make it your ambition to identify high need local populations and tailor services to them. Although digital healthcare has a place in treating hypertension, it is important to recognise the risk that digital exclusion will lead to increasing health inequalities if this is not carefully considered and addressed.

3. Use what is already available to you – don’t duplicate  

Improving health literacy is a vital cornerstone of this work: educating our communities about BP, what it is and how to record and manage it. Know your Numbers is a health campaign that runs every September.[7] There are toolkits which are available online and through your ICS/regional communications teams, with lots of material you can signpost to or personalise. Yorkshire Healthy Hearts is also a place to look and have done extensive resources for patients and professionals.[8] They have videos and leaflets in different languages.

Another resource that has been developed during the pandemic, which colleagues may not be aware of, is the UCL Partners Proactive care frameworks initiative. Hypertension is one of the long-term conditions for which they have developed a real world framework to support proactive care. The frameworks include pathways for remote care, support for virtual consultations and more personalised care, and optimal use of the wider primary care team, eg, healthcare assistants, link workers and pharmacists. Additionally, the frameworks include a selection of appraised digital tools, training and other resources to support patient activation and self-management in the home setting. This work has been led by primary care clinicians and informed by patient and public feedback.[9] I would highly recommend this resource to colleagues – it will also be of help with the personalised care specification due to be implemented in 22/23.

Remember also that most ICSs will have CVD Prevention groups and they will already be working on these initiatives. In addition, it is worth connecting with other PCN leads – to discuss what can you do at scale, to do the work better but also more efficiently.

4. Use the assets you have available

Maximise your use of BP machines – including the patients who already have these at home, or who are prepared to buy them if asked, and those being given out in the [email protected] project.

Make best use of available technology – some ICS areas have purchased new tools for their practice on bulk. For example, the AccuRx Florey tool for BP monitoring, and other tools with similar features such as Ardens Manager and Connected Care. It may be that primary care teams have not yet have had the headroom to learn about them. It is worth asking what is available to your teams and having a play on your clinical systems. There is no doubt it has been a challenge to always keep pace with the tools available to us.

Take opportunities afforded through vaccination clinics – as we do our booster campaigns there is a patient footfall where BPs can be done. Several vaccination centres have already started this – look out for case studies about Making Every Contact Count and borrow ideas and learning where you can.

Work with your community pharmacies – the NHS Community Pharmacy Hypertension Case-Finding Advanced Service started on 1st October 2021.[10] It is worth finding out over the next few months if any of your community pharmacies are signed up.

5. Know your PCN CVD figures and discuss them with your practices  

Public Health England published CVD prevention packs in February 2021, as part of the ‘Fingertips tools’ online resource, to provide information for the CVD prevention project and compare local diagnosis and treatment figures in relation to national CVD prevention ambitions.[11]

Each sustainability and transformation partnership (STP) pack contains STP, CCG and practice level information. The most recent edition includes additional information about behavioural risk factors and NHS Health Checks. Actions to address behavioural risk factors across the entire CVD pathway, alongside clinical interventions, can make a significant contribution to achieving the national CVD ambitions. These packs can give you an idea of where to focus for your PCN.

Talking to your practice teams is critical. Make time to listen to what they are already doing, what they would like support with and what their ideas are. As PCN leaders, learning about barriers to implementing our work is vital if we are to move them out of the way.

Dr Hannah Morgan is a GP, Clinical Director for Hayling Island and Emsworth PCN and South-East Regional Cardiac Network Clinical Lead for CVD Prevention and Cardiac Rehabilitation



1. British Heart Foundation (2018) UK Factsheet November 2018. Available from:—uk-factsheet.pdf

2. NHS England. The NHS Long Term Plan – online version. Chapter 3. Cardiovascular disease [Accessed 28.10.21]

3. NHS Digital. QOF 2020/21 results

4. NICE Impact cardiovascular disease prevention

5. NHS England. Home blood pressure monitoring

6. Blood Pressure UK. [Accessed 28.10.21]

7. NHS England Letter – Annex  B. Published 21 August 2021; updated 1 October 2021

8. NHS West Yorkshire and Harrogate – Healthy hearts: blood pressure

9. UCL Partners Proactive care framework. Hypertension: managing high blood pressure and cardiovascular risk

[Accessed 28.10.21]

10. NHS Business Service Authority. NHS Community Pharmacy Hypertension Case-Finding Service. [Accessed 28.10.21]

 11. Public Health England. Cardiovascular disease prevention packs.


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