Cambridge and Peterborough
Hypertension Optimisation Programme

In partnership with Cambridge & Peterborough ICB and
ECLIPSE (Equality of Care Led Insights for Patient Safety & Engagement)

Practice Pro-Forma

Project overview:

Cardiovascular Disease (CVD) causes a quarter of all deaths in the UK and is a major driver of health inequalities, accounting for a quarter of the life expectancy gap between deprived and affluent communities. Around 30% of people with hypertension are unaware of their condition, and pre-pandemic Quality and Outcomes Framework (QOF) data showed that around 1/3 of people with diagnosed hypertension are not treated to target, with substantial variation across the country.

Hypertension Optimisation is a programme that forms part of the wider “Your Healthier Future” initiative being offered to practices throughout Cambridgeshire & Peterborough over the next two years.

The programme aims to identify and engage with patients:

  • To ensure that patients with coded hypertension have an up-to-date blood pressure (within 12 months).

  • To ensure that patients with coded hypertension and a blood pressure above their age-appropriate treatment threshold are monitored, reviewed, and optimised.

There are two tiers of support on offer to improve these metrics for practices:

  1. Practice Patient Engagement – Activation of this programme will activate the Hypertension Optimisation pathway within Eclipse, providing a list of all eligible patients, alongside additional priority groups, which can be further filtered and prioritised by parameters such as levels of deprivation, ethnicity, comorbidities, and risk.

  2. Eclipse Patient Engagement – Activation of this programme will automatically engage with prioritised patients via the PEGASUS platform to inform, educate, and invite patients to provide an updated blood pressure via an online questionnaire. If desired, telephone patient engagement to non-responders can be activated to allow a team of motivational interviewers to contact your patients to complete the questionnaire. Patient consent and preferences will be captured within Eclipse and prompt follow-up action aligned with this. This could include an up-to-date blood pressure being obtained by the practice or community pharmacy, or the arrangement of home blood pressure testing. A summary patient report can be generated for patients containing the relevant data and any suggested follow-up management considerations.

COHORTS:

The system enables identification of patient cohorts eligible for the programme, such as:

  • Aged 18 and over, coded with hypertension, who have not had a blood pressure in the last 12 months.

  • Aged 18-79, coded with hypertension, with an up-to-date blood pressure >140/90.

  • Aged >=80, coded with hypertension, with an up-to-date blood pressure >150/90.

These priority groups can be further filtered and prioritised by parameters such as levels of deprivation, ethnicity, comorbidities, and risk.

REMUNERATION:

This patient support programme is part of the Cambridgeshire & Peterborough Your Healthier Future programme. There will be some additional funding for practices participating in this programme. Practices have three choices:

  1. Practice Patient Engagement - Practices that would like to activate Practice Patient Engagement to risk stratify and identify patients for Hypertension Perfect, will undertake patient engagement, reviews, and follow-up through their own practice team. Payment to practice is set at £1,000 if the target* is met.

  2. Eclipse Patient Engagement - Practices that would like to activate Eclipse Patient Engagement will have all patient engagement undertaken for them through a centralised patient support hub. Payment to practice is set at £400.

  3. No participation - Practices that would not like to utilise either Practice Patient Engagement or Eclipse Patient Engagement will not receive any additional financial remuneration for the Hypertension Optimisation programme.

*Individual practice targets will be based on practice performance for each of the metrics being targeted in the Your Healthier Future programme. These targets have been approved by the ICB and require an equal effort from all practices within an upper and lower threshold.

EVALUATION: As well as quantitative data, which will be collected via Eclipse, patient reported outcomes and perceptions of the new pathway will be collected through patient questionnaires.

The programme uses Eclipse to identify eligible patients, support clinical decision-making, and enable centralised reporting. To support broader system learning and clinical audit, anonymised data will be evaluated to understand health inequalities, intervention impact, and service effectiveness. 

All evaluation is GDPR-compliant and includes only aggregated, anonymised data. No identifiable information will be shared in reports. 

Data Protection and Information Governance 

This programme evaluation is compliant with UK GDPR and the Data Protection Act 2018. 

  • Lawful basis for processing: 
     - Article 6(1)(e) – public task 
     - Article 9(2)(h) – provision of health or social care 

  • Only aggregated, anonymised data will be included in evaluation outputs. 

  • A full Data Protection Impact Assessment (DPIA) and Data Sharing Agreement (DSA) are available upon request. 

  • Prescribing Services Ltd is fully accredited under the Data Security and Protection Toolkit. 

  • Cambridgeshire & Peterborough ICB remains the data controller for evaluation activities. Eclipse (Prescribing Services Ltd) acts as a data processor under contract and data sharing agreement. 

If your practice would like to take part: Please complete the below pro forma, expressing your interest and permissions for patient engagement.

Please note that you will be notified prior to any active patient engagement, and your practice will be issued with a guide on how to view patient lists and document patient reviews.