NHS Mid and South Essex
CVD Detect & Perfect Programme
In partnership with NHS Mid and South Essex and ECLIPSE (Equality of Care Led Insights for Patient Safety & Engagement) and funded by MSE Health Inequalities sponsorship. The scheme will launch on 29th September 2025 and run until 31st March 2027.
Practice Pro-Forma
Background:
Hypertension is a significant and independent risk factor for the development and progression of cardiovascular disease, amplified through associations with high BMI, dyslipidaemia, and metabolic disorders such as chronic kidney disease and type 2 diabetes. Additional complications include cancer (breast, colon and endometrial), arthritis and fatty liver disease. An up-to-date blood pressure reading is important for identifying those who may benefit from intervention such as onward referral or hypertensive-adjusted medication dosing.
71% of MSE patients aged 18+ have their hypertension managed to NICE guidance levels (as of March 2025, CVD PREVENT). There is a further estimated 88.4k patients with undiagnosed high blood pressure in MSE (OHID, 2021). This usually symptomless condition significantly increases the risk of heart attacks, stroke, and dementia. NHS ambitions are that by 2029, 80% of the expected number of people with hypertension are diagnosed, and that 80% of the total number of people diagnosed with hypertension are treated to target.
Aim:
To create holistic pathways that engage patients in managing hypertension and risks associated with cardiovascular disease, whist also directing them to appropriate advice and care. The programme will initially focus on patients aged 20-65 years old who have a latest systolic blood pressure above or equal to 140 mmHg.
Objectives:
To ensure that patients with a previous high blood pressure reading, not coded with hypertension, have an up-to-date blood pressure (within 12 months).
To ensure that patients diagnosed with hypertension have an up-to-date blood pressure recording (annually).
To ensure that patients with an elevated up-to-date blood pressure are appropriately followed up and, where appropriate, coded with hypertension.
To increase recording of BMI, smoking status, home and pharmacy BP measurements.
To increase service engagement for weight management, stop smoking services and NHS 40+ Health Checks.
To support practices in identifying and engaging patients who would benefit from the programme, while also helping them maximise their QOF points.
Project overview:
All practices signed up to the programme will gain access to their region’s tailored Eclipse pathways, including a list of all their eligible patients cohorted according to the following methodology:
Cohort: Patients aged between 20-65 years old, with a latest systolic blood pressure ≥140 mmHg.
These patients will be grouped into either Hypertension Detect or Hypertension Perfect pathways, and within these, each allocated to intervention groups according to the management they may be eligible for:
Detect: for patients not on the hypertension register, requiring further blood pressure measurement, potential confirmation of diagnosis and wider CVD risk reduction
Intervention subgroups: Eligible for Health Checks, eligible for Smoking cessation services, eligible for Weight Management services
Perfect: for patients on the hypertension register, requiring further blood pressure management and wider CVD risk reduction
Intervention subgroups: Eligible for Smoking cessation services, eligible for Weight Management services
Patient lists can be filtered by factors such as deprivation level, age, gender, and ethnicity. This allows practices to focus on specific patient groups and engage directly with those who are eligible for certain interventions.
For enhanced support, practices can opt into the ECLIPSE PEGASUS stream of patient engagement (follow this link for more information), which enables Eclipse to directly contact patients to support and optimise their journey through the programme on behalf of their practice.
PEGASUS (Patient Engagement Governance Assuring Standardised Utilisation of Services) is the ECLIPSE centralised engagement model, designed to provide equitable, digital-first support for priority patient groups. Non-responding patients will be followed up via telephone by the Virtual Support Team to increase uptake and ensure equity of access to care.
Through PEGASUS, Eclipse will directly engage with your patients to:
Inform, educate, and counsel on high blood pressure and CVD risk
Capture additional risk factors via a dynamic questionnaire
Assess openness to support services, including national and local options
Following engagement, GPs and prescribers will complete any outstanding actions linked to the patient’s assigned cohort. In most cases, this will mean signposting or referring patients to local services for blood pressure monitoring, NHS Health Checks or wider CVD risk management support.
Patient Portal:
Patients will be encouraged to submit their updated blood pressure readings from the community into Eclipse via their patient portal. This portal securely returns data to Eclipse and can generate clinical alerts for GPs to action. Your practice will remain the data controller for this information and therefore responsible for reviewing and acting on any alerts that arise.
For practices that opt out of the patient portal, patients will become the data controller for their own information. They should be advised to provide updated measurements directly to the practice for entry into your clinical systems. Practices are expected to make patients aware of this arrangement and offer clear guidance on how to manage their blood pressure readings, including what to do if results are abnormal.
Evaluation:
As well as quantitative data, which will be collected via Eclipse, patient reported outcomes and feedback for the new pathway will be collected through patient questionnaires. By taking part in this programme, you will also be providing permission for anonymised, aggregated data derived from your eligible patient cohort to be included in the overall service evaluation.
| Features | Practice-led Engagement | PEGASUS-led Engagement |
|---|---|---|
| Eclipse pathways & lists | Lists available to access by practices to manage engagement. | Lists available to access by practices + enhanced by Eclipse engagement & sub-cohorting. |
| Patient experience | All contact managed by GP. | Digital messages, education, dynamic questionnaires, telephone follow-up (Virtual Support Team). |
| Patient support | GP-led signposting for all support services and interventions | Eclipse assesses patient openness to relevant support services for signposting. |
| Patient portal | Available – Patients directed to the portal by GP practices | Available – Patients guided to the portal by Eclipse |
| Patient feedback for Evaluation | Available – Patients directed to the portal by GP practices | Available – Patients guided to the portal by Eclipse |
| Outcome monitoring | Outcomes tracked with intermittent reporting to practices | Outcomes visible in real time via the Eclipse dashboard, with longitudinal tracking and dynamic sub-cohorting |
Preferences:
If your practice would like to take part: Please complete the below pro forma, expressing your preferences, key contacts and permissions for patient engagement and data sharing.
Please note that you will be notified prior to any active patient engagement, and your practice will be issued with guidance on how to view patient lists to implement appropriate patient actions.