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Reducing the disease burden for hypertension – how an integrated approach is improving patient care

Our latest video case study highlights how using the Proactive Care Frameworks can promote collaborative working in primary care and improve patient outcomes.

UCLPartners speaks to Dr Vaishali Ashar, GP in Newham, North East London and Darshana Lithagra, Health and Wellbeing Coach, to hear their experiences in implementing the hypertension UCLPartners Proactive Care Framework. They discuss the process and give a patient example of how it can work in practice, demonstrating how an integrated approach can improve patient care.


Newham is a socially deprived area of London and the Proactive Care Frameworks for hypertension were introduced to focus on the higher health inequality gap in their population. Newham has a population of 73.2% non white ethnic minority groups. Heart disease and lung and respiratory disease are some of the most common causes of premature death and long term illness in the area.

North East London was one of the pilot sites for implementing the Proactive Care Frameworks to try and improve patient outcomes with long term cardiovascular diseases. The flexibility and ability to adapt the frameworks to suit local needs was key when working with UCLPartners in the pilot phase.


The risk stratification and prioritisation helped primary care staff to identify high risk cohorts which required a clinician’s input right at the outset. High risk category patients were seen by clinical pharmacists, advanced nurse practitioners and GPs. The moderate risk group were addressed by nursing colleagues and HCAs and the low risk seen by health and well being coaches and health care assistants.


Stratification as per the frameworks has helped release GP time by allowing patients to be seen by the appropriate professionals from the wider team. They have also managed to empower patients to take control of their health and well being, especially in the low risk category groups through education videos, leaflets and virtual patient participation groups.

With one collaborative intervention across the team, focussing on patient care on the basis of the proactive care framework, they were able to demonstrate significant reduction in the disease burden in their population.

The written up frameworks and pathways were instrumental in bringing the team together for a common purpose in helping improve the patient outcomes. The frameworks provided autonomy to each of the roles with clear goals of what they were trying to achieve for the patient.

How the frameworks work in practice by using the wider workforce:

The frameworks have helped to provide proactive and targeted treatment for patients, and enable staff to signpost the right patient to the right medical professional, and take an integrated approach to healthcare.

Example patient which was seen:

A patient was referred for health coaching to reduce his cholesterol levels, he hadn’t been seen in two years due to the pandemic. The health and well being coach who saw him picked up signs of angina and engaged with the pharmacist who then was able to review his medication. He was given British Heart Foundation resources around healthy eating and exercise to improve his diet and lifestyle and a 24 hour BP monitoring kit. The practice use Accurx to communicate with patients by sending them videos on health and wellbeing and also do the voice group consultations which they have had training for.

Next steps

Having seen the benefits this was approach was demonstrating, other practices in the PCN decided to explore the diabetes frameworks to meet the needs of their population where this was a major concern with a high number of patients with type 2 diabetes. North East London practices are also exploring and looking at implementing the COPD, Asthma and Atrial Fibrillation frameworks and have started looking at their data for these areas.

The frameworks have been invaluable in helping us provide better care to our patients by prioritising and making use of the wider staff team. To date the results have been so positive for hypertension optimisation that we are now planning a further roll out, for other long term conditions.

Dr Vaishali Ashar, GP in Stratford

Proactive care frameworks

Our online support package contains tools and resources to help primary care teams to continue to effectively deliver proactive care for patients with CVD and respiratory conditions.

View the frameworks