QOF Cardiovascular Disease Business Rules Guidance for 2025/26

Executive Summary

This toolkit provides a practical roadmap for General Practices to navigate the 2025/26 GP Contract’s renewed focus on cardiovascular disease (CVD) prevention and management. Under the latest contract changes, 32 existing Quality and Outcomes Framework (QOF) indicators have been removed, and 141 points (around £198 million of funding) have been reassigned to a dedicated CVD prevention domain. Practices will see substantially increased rewards for controlling blood pressure and cholesterol, along with elevated performance thresholds—often 85–90% of the target population—for maximum points.

Key Highlights:

• New CVD Emphasis in QOF: Nine primary indicators now drive QOF points for hypertension, coronary heart disease, stroke, and diabetes. Secondary prevention is a core priority; nearly all eligible patients should be on statins and have their blood pressure or cholesterol levels at recommended targets.

• Raised Performance Thresholds: While lower thresholds remain relatively modest (20–46%), upper thresholds have jumped to 85–90% in most cases, indicating an expectation of near-universal coverage or properly coded exceptions.

• Impact on Practice Income: Collectively, these CVD indicators can generate significant QOF income—potentially 141 points’ worth—making thorough disease coding, proactive recalls, and rigorous treatment protocols crucial for financial viability.

• Implementation Strategies: The toolkit outlines step-by-step approaches, from accurate register coding and targeted recalls to intensive medication reviews and team-based clinics. Practices are encouraged to harness IT systems for data-driven intervention, use exception reporting responsibly, and involve patients in shared decision-making to optimize adherence.

• Practical SOP and Best Practices: A detailed Standard Operating Procedure (SOP) framework is provided, covering identification of at-risk patients, structured reviews, lifestyle interventions, and intensification of therapies (including statins and combination antihypertensives). Recommendations emphasize regular follow-up, blood monitoring, and using tools such as home blood pressure monitoring and pharmacist-led reviews.

• Broader CVD Care Integration: While QOF highlights specific metrics, comprehensive CVD care involves addressing comorbidities (like heart failure, atrial fibrillation, diabetes) and ensuring patients receive the full suite of recommended treatments (antiplatelets, anticoagulation, SGLT2 inhibitors where appropriate).

By systematically applying these measures—accurate registers, meticulous treatment intensification, and targeted patient engagement—practices can meet the new, higher standards. More importantly, they will deliver better cardiovascular outcomes and reduce future disease burdens, fulfilling both the clinical and contractual aims of the 2025/26 GP Contract.

Disclaimer

This document and all information contained within it are provided strictly for informational purposes and do not constitute legal, financial, or clinical advice. It is intended to help GP Partners and Practice Managers understand the CVD-related QOF business rules in General Practice. While clinical details are included to contextualize these rules, they should not be relied upon for diagnosis, treatment, or any other medical use.

GP Contract 2025/26 Analysis

QOF 2025/26 – New Focus on CVD

The GP Contract for 2025/26 introduces significant changes to the Quality and Outcomes Framework (QOF) aimed at bolstering CVD prevention (NHS England » Changes to the GP Contract in 2025/26) (GP contract 2025/26 changes). A total of 32 QOF indicators (worth 212 points) that were temporarily income-protected in 2024/25 have been permanently retired (NHS England » Changes to the GP Contract in 2025/26) (GP contract 2025/26 changes). The funding from these retired indicators has been reallocated. About 71 points (~£100 million) were removed from QOF entirely and moved into the Global Sum and targeted payments (e.g. higher item fees for childhood immunisations and better locum reimbursement) (NHS England » Changes to the GP Contract in 2025/26). The remaining 141 points (~£198 million) have been redirected to a “CVD prevention” domain, dramatically increasing the QOF reward for managing blood pressure and cholesterol in at-risk patients (NHS England » Changes to the GP Contract in 2025/26) (GP contract 2025/26 changes). These 141 points are distributed across nine key CVD indicators, with an emphasis on secondary prevention and risk factor control. Crucially, while the lower achievement thresholds for these indicators remain at 2024/25 levels (to allow practices to earn some points more easily), the upper thresholds have been raised for 2025/26 to drive improved performance (NHS England » Changes to the GP Contract in 2025/26) (GP contract 2025/26 changes). In practical terms, to earn maximum QOF points, practices will need to attain higher coverage of risk factor control – often 85%–90% of the target population, compared to upper thresholds in the 70–80% range last year.

Revised CVD Indicators and Points (2025/26)

Below summarizes the nine QOF indicators that now carry the bulk of CVD points, with their achievement thresholds and point value for 2025/26 (changes from 2024/25 in bold):

• CHOL003 – Statin prescribing in CVD/CKD: Percentage of patients on the CHD, PAD, Stroke/TIA or CKD registers on a statin (or with documented intolerance/exception). Worth 38 points (up from 14), with threshold 70–95% (unchanged) (NHS England » Changes to the GP Contract in 2025/26). Implication: Nearly all patients with these conditions should either be on lipid-lowering therapy or have a reason coded if not. The inclusion of CKD here highlights chronic kidney disease as a CVD risk equivalent. Ensure robust processes for offering statins to CKD stage 3b–5 patients. (Note: Icosapent ethyl was removed as an alternative in this indicator, per technical update (NHS England » Changes to the GP Contract in 2025/26), reinforcing that statins are the primary therapy.)

• CHOL004 – Cholesterol control in established CVD: Percentage of patients on the CHD, PAD, Stroke/TIA registers with last cholesterol at target (LDL ≤2.0 mmol/L or non-HDL ≤2.6 mmol/L) in the past 12 months. Worth 44 points (up from 16). Threshold range widened 20–50% (was 20–35%) (NHS England » Changes to the GP Contract in 2025/26). This new indicator, aligned with NICE indicator IND278 (NHS England » Changes to the GP Contract in 2025/26), incentivizes intensive lipid management – at least half of patients with cardiovascular disease should reach a tight cholesterol target. Practices will need to optimize statin therapy, consider add-ons (ezetimibe or PCSK9i if eligible), and re-check levels to meet this. It’s a shift toward outcome-based performance (cholesterol level) rather than just prescribing. Tip: Prioritize follow-up blood tests at 3 and 12 months after statin adjustments to capture improvements.

• HYP008 – BP control in Hypertension (<80 years): Percentage of hypertensive patients under 80 with BP ≤140/90 mmHg (or home BP ≤135/85) in last 12m. 38 points (up from 14); threshold 40–85% (upper target raised from 77%) (NHS England » Changes to the GP Contract in 2025/26). This is a major points increase, reflecting hypertension as a top priority. To earn full points, 85% of non-elderly hypertensives must be at target. Many practices will need to intensify their recall and medication titration processes to reach such a high control rate (NHS England » Changes to the GP Contract in 2025/26). Using home BP readings can help include patients whose clinic BP is higher than their true control.

• HYP009 – BP control in Hypertension (≥80 years): Percentage of hypertensive patients 80+ with BP ≤150/90. 14 points (up from 5); threshold 40–85% (upper target up from 80%) (NHS England » Changes to the GP Contract in 2025/26). More weight is given to controlling BP in the elderly, but note the less stringent BP target for this age group. Practices should still aim for <150/90 in most ≥80s, except where not appropriate due to frailty.

• CHD015 – BP control in Coronary Heart Disease (<80): CHD patients under 80 with BP ≤140/90. 33 points (up from 12); threshold 40–90% (upper target up from 77%) (NHS England » Changes to the GP Contract in 2025/26). CHD patients overlap with hypertension but often require even more intensive management. This high upper target (90%) means virtually all but a few CHD patients should have well-controlled BP, or be excepted if not achievable. It underscores that stable angina/MI patients should be on optimal doses of BP medications (often ACEi and beta-blocker).

• CHD016 – BP control in CHD (≥80): CHD patients 80+ with BP ≤150/90. 14 points (up from 5); threshold 46–90% (upper up from 86%) (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26). Similar to HYP009 but for those with CHD; again a higher cap (90%). Even very elderly CHD patients, if fit, are expected to be controlled, with clinical judgment on frailty.

• STIA014 – BP control in Stroke/TIA (<80): Patients <80 with stroke/TIA history, BP ≤140/90. 8 points (up from 3); threshold 40–90% (upper target dramatically up from 73%) (NHS England » Changes to the GP Contract in 2025/26). This is a striking change – previously only ~73% needed control for max points, now 90%. Secondary prevention after stroke is critical (to prevent recurrent strokes), so practices must aggressively manage these patients’ BPs, often requiring multiple medications and close monitoring.

• STIA015 – BP control in Stroke/TIA (≥80): Patients 80+ with stroke/TIA, BP ≤150/90. 6 points (up from 2); threshold 46–90% (upper up from 86%) (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26). Similar rationale as CHD016. Many post-stroke patients are older; careful balance needed between preventing stroke and avoiding hypotension/falls, but QOF expects most to be controlled under 150/90.

• DM036 – BP control in Diabetes (<80 without frailty): Diabetic patients <79 with no moderate/severe frailty, BP ≤140/90. 27 points (replacing previous 10-point indicator); threshold 38–90% (upper up from 78%) (NHS England » Changes to the GP Contract in 2025/26). This new indicator (replacing DM033) aligns diabetes care with the same <140/90 target (NHS England » Changes to the GP Contract in 2025/26). It excludes frail patients and those ≥80 (who have separate BP targets or considerations). Achieving 90% control in diabetics is challenging – they often have complex hypertension – so this will require robust review systems. It’s now one of the highest-value diabetes indicators.

(Note: There are also two updated QOF indicators for statin use in diabetes: DM034 covers statin in diabetics ≥40 with no CVD, and DM035 covers diabetics with CVD on statin. These were updated for 2025/26 to include exceptions and align with NICE guidance (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26). While their point allocation didn’t change as dramatically as the nine above, they remain important: practices should ensure nearly all diabetic patients are coded as on statin or exception. We focus on the nine main CVD indicators above, as they absorbed the reallocated 141 points.)

Performance Threshold Changes

For all the above indicators, the lower threshold (the level of achievement to start earning points) remains relatively low (ranging 20–46% for most, 38–40% for BP control in diabetes and hypertension) (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26). This is intentional to give every practice a chance to earn some points. However, the upper thresholds (the performance needed for full points) have been significantly raised – mostly to 85% or 90%, as noted (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26). By comparison, last year’s upper targets were in the 73–80% range for these indicators. The raised bar means practices must reach more of their population. For example, to get maximum points for HYP008 now requires 85% of under-80 hypertensives controlled, versus 77% before (NHS England » Changes to the GP Contract in 2025/26). Similarly, 90% control is needed in CHD, Stroke, and diabetic groups for full points. These higher targets reflect an expectation of near-universal management, accounting for only a small minority of exceptions or outliers (e.g. those who truly can’t reach targets). It will be important to identify patients who can be legitimately exception-reported (e.g. those who decline treatment or are frail) so that the denominator for these indicators reflects only those in whom treatment to target is feasible. Otherwise, missing these ambitious thresholds could leave points on the table.

Strategies to Optimize QOF Performance (CVD Indicators)

• Maximize Disease Register Accuracy: Underpinning all QOF indicators is having patients correctly coded on the relevant registers (Hypertension, Diabetes, CHD, Stroke/TIA, CKD, etc.). Conduct searches to identify uncoded patients (for instance, those with multiple high BP readings but no hypertension diagnosis) and code them appropriately early in the year. This not only ensures funding (prevalence adjustment) but allows proactive management. Similarly, ensure any patient with diagnoses like MI, CABG, TIA, peripheral vascular disease is added to the respective QOF register – this flags them for recall and inclusion in statin/BP indicators.

• Carefully Review Exception Reporting: Exception reporting is a legitimate tool, but it should be used judiciously. With thresholds so high, some patients will inevitably need to be excepted (e.g. those who truly cannot tolerate statins or have resistant hypertension despite maximum therapy). Document exceptions meticulously – e.g. if a patient refuses a statin, code “statin declined” (Read code or SNOMED) which will exclude them from CHOL003 and DM034 denominators (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26). If a patient has serious side effects or contraindications, code that. Use exceptions after reasonable attempts at intervention: e.g. at least invite patients 2–3 times for reviews before exception coding for non-attendance (per QOF business rules). Appropriate exception coding prevents skewing your achievement percentage when clinical care cannot be delivered due to patient factors. That said, high exception rates are scrutinized, so focus on improving care and use exceptions for cases of informed dissent or clinical unsuitability rather than as a broad escape clause.

• Data-Driven Recall and Tracking: Leverage your clinical IT system to identify patients not meeting targets. For each indicator, run monthly or quarterly searches: e.g. list all CHD patients with last BP >140/90, or all stroke patients without a recorded BP in last 12 months, all CHD/PAD/stroke patients with LDL >2.0, etc. These lists form your target cohort for intervention. Many systems (EMIS Web, SystmOne) have QOF report or radar charts that show current achievement – monitor these dashboards. Consider using tools like patient stratification: highlight those closest to the target (e.g. recent BP 145/95) who might be easily brought into control with a small tweak, versus those far off (BP 180/100) who need intensive follow-up. Also, flag patients who are missing data – e.g. no recent cholesterol check – as they count as not meeting the indicator until a new result is in.

• Implement a Recall System: High achievement requires consistent patient follow-up. Set up a robust recall system for annual reviews of each disease area, and interim recalls for those above targets. For example, hypertension – if last BP >140/90, recall in 4 weeks after med change; if last BP <140/90, still ensure at least an annual check. Use a variety of contact methods: letters, texts, patient online messaging, and phone calls (see Practice Questionnaire and Appendices for templates). Ensure your team schedules these in advance (e.g. run recall lists at the start of each quarter for those due). Aim to complete the bulk of annual reviews by Q3 so that Q4 is left for mop-up of defaulters.

• Optimize Clinical Interventions: The clinical strategies in section 1 need to be applied systematically. For BP control, consider a protocol where if a patient’s BP is above target, they are seen in a focused hypertension clinic or by a pharmacist for medication titration every 2–4 weeks until controlled. Standing orders or PGD can allow nurses or pharmacists to uptitrate common medications (ACE inhibitors, diuretics) within agreed parameters, speeding up control. For cholesterol, make sure every patient on the CVD registers has been assessed for statin therapy – if not on a statin, there should be a documented reason. Given the high value of CHOL003, work on converting “exceptions” into “inclusion” where possible: e.g. a patient who stopped statin due to minor muscle aches might tolerate a lower dose or a different statin – invite them for a medication review rather than leaving them permanently excepted. Re-check lipid levels 3 months after any change and again later; whenever a patient comes in for a blood test (for diabetes or thyroid, etc.), consider adding a lipid profile if they are above target and due for recheck – opportunistic monitoring helps achieve CHOL004.

• Use Team Roles and Meetings: Involve the whole practice team in QOF CVD performance. For example, a practice pharmacist can take the lead on identifying patients not on optimal therapy (e.g. diabetics without statins, hypertensives on sub-maximal doses) and arrange medication reviews. Practice nurses can run clinics for blood pressure, including proper measurement and lifestyle counseling sessions. Healthcare assistants can do blood pressure readings, weight, and lifestyle form updates ahead of clinician appointments to save time. Hold a monthly clinical meeting to review QOF progress: e.g. present how the practice is doing on each CVD indicator, identify any shortfalls. If, say, the stroke BP control percentage is lagging, come up with an action plan (perhaps devote one nurse clinic per week to calling in stroke patients with high BP). Also, share performance transparently – a visual chart on the staff noticeboard of current percentages vs targets can motivate the team.

• Patient Engagement and Education: Achieving high thresholds means patients need to be cooperative and informed. Invest time in patient education for why these targets matter. When initiating a statin or additional BP pill, explain how this reduces their risk of heart attack or stroke by a substantial percentage, linking to something tangible (e.g. “This will help you stay healthy and out of hospital”). Educated patients are more likely to adhere to medications and attend follow-ups. Use leaflets, or direct them to NHS website resources, for reinforcement. Also, consider group education sessions or virtual webinars for conditions like hypertension or cholesterol – peer discussion can improve motivation.

• Contract Constraints and Efficiency: The contract changes free up some effort by removing 32 less critical indicators, allowing more focus on CVD. Take advantage of that by reallocating clinician time that might have gone into, say, less impactful reviews (some retired indicators may include certain mental health or asthma processes) into CVD clinics. Also note that with funding shifting into Global Sum, some income is guaranteed irrespective of QOF for those retired areas, but the CVD points are not guaranteed – they must be earned. Therefore, prioritize these nine indicators in your QOF planning. It may help to set internal targets a bit above the QOF upper thresholds to give a safety margin. For instance, aim for 92–95% BP control in CHD/stroke patients to comfortably exceed the 90% threshold and buffer any data recording issues.

• Leverage Network and Incentives: The 2025/26 contract puts system focus on CVD; there may be additional support via your Primary Care Network (PCN) or Integrated Care Board. For example, some areas have CVD facilitators or funded projects for detecting hypertension or optimizing lipids (such as the NHS England “Lipid Management Pathway” initiative that provides inclisiran and specialist advice for tough cases). Make use of these – refer patients to lipid clinics when appropriate (e.g. if considering PCSK9 inhibitors for extremely high LDL). PCNs might also pool resources for patient education events or share a specialist pharmacist for CVD. Aligning your practice strategy with these wider efforts can improve outcomes and lighten practice workload (e.g. a PCN-wide hypertension project might provide extra nurse clinics or home BP monitors).

By implementing these strategies, practices can maximize QOF achievement under the new contract while genuinely improving patient care. The additional income from potentially 141 points in CVD (which at ~£200 per point nationally, scaled by practice prevalence and list size, is quite significant) will reward the practice for these efforts. Continuous monitoring and adaptation are key – track your progress, identify barriers early (e.g. if patients are declining statins en masse due to misinformation, do a targeted education campaign), and ensure no patient “falls through the cracks” un-reviewed. With methodical management, even the higher thresholds are attainable, as many high-performing practices already achieve 80–90% control rates through diligent work ( Lowering blood pressure reduces the risk of heart disease, stroke and death ). The contract’s message is clear: prevention is prioritized, and practices that excel in CVD prevention will benefit both clinically and financially.

SOP 

The following is a step-by-step blueprint for identifying, coding, and managing patients at risk of cardiovascular disease in a GP practice. This SOP can be customized to different practice settings (large urban, small rural, deprived community, etc.) as noted. It incorporates best practices for statin prescribing, blood pressure monitoring, patient safety, and exception reporting.

Foundation SOP for CVD Management in Practice

Step 1: Identification of At-Risk Patients and Register Coding

1. Compile and Verify Disease Registers: Use clinical system searches to update your registers for hypertension, diabetes, CHD (coronary heart disease), stroke/TIA, CKD, and atrial fibrillation. Ensure every known patient with these conditions is correctly coded:

   • Hypertension: Query patients with multiple recent BP readings ≥140/90 with no hypertension diagnosis – flag them for review/diagnosis confirmation.

   • Pre-diabetes/At-risk: If available, also note patients with pre-diabetes or high QRISK scores who might not be on any register but are candidates for prevention.

   • CHD/Stroke: Ensure all patients with a history of MI, angina, angioplasty, CABG, stroke or TIA are on CHD or Stroke registers. Cross-check hospital correspondence (discharge summaries) for any missed diagnoses.

   • CKD: Identify CKD stage 3b+ (eGFR <45 or proteinuria) patients, since they benefit from CVD risk management similar to CHD.

   • Diabetes: Ensure Type 2 diabetics are coded and differentiated from gestational or Type 1 (different pathways).

   • Heart Failure, AF: While not explicitly in the earlier QOF list, also update HF and AF registers as these have CVD implications (AF patients need stroke prevention, etc.).

2. Risk Stratification: From your population, generate a list of patients who are “at risk” but perhaps not yet on a chronic disease register:

   • Patients over 40 with no CVD who have a QRISK3 ≥10% (if your system can calculate QRISK batchwise). These patients qualify for primary prevention (lifestyle advice and likely statin consideration) even if they have no single diagnosis.

   • Patients with persistent significant risk factors: e.g. heavy smokers >40, strong family history of premature CVD, or obesity with metabolic syndrome. They may warrant earlier intervention – ensure they’ve had a formal risk assessment.

   • This “risk cohort” can be flagged for clinician review to consider interventions (e.g. blood tests, blood pressure check, risk score calculation) even if they aren’t captured by a QOF indicator.

3. Coding and Template Setup: Use standard codes for risk factors and ensure proper coding for exclusions:

   • Enter latest smoking status codes for all adults (ex-smoker, current, never) – smoking is a big driver of QRISK and important for advice.

   • Record ethnicity (relevant to risk calculations and tailoring advice).

   • If a patient declines a preventive treatment (e.g. statin, antihypertensive), code the refusal explicitly (e.g. “Statin therapy declined by patient”) – this serves both clinical documentation and QOF exception purposes (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26).

   • Set up EHR templates for CVD annual reviews that prompt for all relevant checks (BP, cholesterol, HbA1c, lifestyle, foot exam for diabetics, etc.). Many systems have pre-built templates (e.g. Ardens or QOF templates); customize them to your workflow.

   • Accuracy check: for each register, run the prevalence reports and compare with previous year – if there’s a drop, investigate if patients were incorrectly exceptioned or codes changed. Aim for stable or increasing register size (it’s unlikely your true disease prevalence drops significantly in one year; drops often indicate coding issues).

Step 2: Proactive Patient Recall and Initial Assessment

1. Patient Recall Scheduling: Develop a recall schedule prioritizing those most at risk:

   • High-risk CVD patients: e.g. patients with established CVD who have not had a review in >6 months, or anyone with extremely high recent readings (BP or cholesterol). Invite these first for a comprehensive review.

   • Annual review batches: Assign each chronic condition a recall month or quarter (e.g. Birthday month recalls, or diabetics in Q2, hypertensives in Q3, etc.). Alternatively, spread reviews evenly to manage workload – e.g. 1/12th of patients each month.

   • Use a recall tracker (spreadsheet or IT system feature) to log when invitations are sent and if patients have booked/attended. Typically:

     • 1st invite: SMS or letter (include information about why review is important).

     • 2nd invite: after 2–3 weeks if no response – another SMS/letter or a phone call.

     • 3rd attempt: personal phone call by receptionist or care navigator. If still no response, consider a final letter stating they will be exception-reported but can contact for an appointment anytime.

   • For hard-to-engage groups, consider more creative outreach (see practice profile adaptations below).

2. Pre-Clinic Data Gathering: Before the patient attends the review appointment, gather preliminary data:

   • Blood tests: Arrange bloods (lipid profile, HbA1c, U&E, LFTs, etc. as needed) before the review visit so results are ready for discussion. E.g. for diabetics, have them do labs a week prior to their annual review appointment.

   • Home BP readings: Ask hypertensive patients to bring a home BP diary if possible (morning and evening readings for 7 days) ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ) ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ). This can be more representative than a single clinic reading and can be used for QOF if properly documented.

   • Questionnaires: Send any relevant questionnaires for completion beforehand: e.g. a lifestyle questionnaire (diet, exercise habits), or condition-specific ones (DQIP for diabetes education, or QRISK consent form if you want to calculate in absentia). For patients with potential frailty, consider a simple frailty screen (e.g. PRISMA-7 questions) to identify if targets should be tailored.

   • Medication list review: Have a pharmacist or GP review the current medications for any obvious gaps (e.g. a post-MI patient not on a beta-blocker or ACE inhibitor, a diabetic with albuminuria not on ACEi). Flag these so they can be addressed at the review.

3. Patient Consultation – Clinical Review: When the patient comes in (or via a structured phone/video review if appropriate):

   • History update: Note any new symptoms or diagnoses since last review (e.g. chest pain, claudication, etc.). For diabetics, inquire about any hypo episodes or complications. For hypertensives, ask about adherence and any side effects from meds (e.g. dizziness).

   • Physical measures: Take at least two BP readings properly (after 5 min rest, right cuff size). If discrepancy >10 mmHg, take additional and use lowest consistent reading ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ) ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ). Record weight, BMI, and waist circumference if weight management is an issue.

   • Lifestyle assessment: Review smoking status, alcohol intake, diet (fruit/veg portions, salt use), and exercise habits. This sets the stage for advice. Even brief advice (e.g. on smoking cessation or diet) has evidence of benefit.

   • Calculate risk: If patient does not have CVD, calculate/update their QRISK3 score using latest data. Share this with them: “Your 10-year risk of heart attack or stroke is X%,” and explain what that means (e.g. moderate vs high). If they have CVD, risk is obviously high; focus on secondary prevention.

   • Check investigations: Review latest blood results: HbA1c for diabetics (discuss control, adjust therapy if needed per NICE NG28 targets), lipid profile (see if at target per NICE/QOF – if not, discuss medication changes), kidney function (important for drug dosing and as a BP target consideration).

   • Screen for complications: Especially in diabetes clinics, perform foot check (pulses, sensation), ask about vision check status, etc. In hypertensives, check for any signs of organ damage (e.g. ask about headaches or get an ECG if long uncontrolled BP to check for LVH).

   • Summarize to patient: “Your numbers today are… (BP, cholesterol, etc.). According to guidelines, we’d like your BP under 140/90 and LDL below 2.0 to best protect you from heart attacks and strokes. Here’s where you stand relative to that.” Use visual aids if possible, like a chart of their past readings trending down or up.

4. Tailoring for Practice Profile: At this stage, consider any specific needs:

   • In a deprived community, be alert to financial or social barriers the patient might have (affording healthy food, gym access, health literacy). Tailor advice accordingly – e.g. refer to free local exercise classes or healthy cooking on a budget resources.

   • In a multilingual urban practice, ensure understanding – use interpreter services or translated print materials for lifestyle advice as needed.

   • For rural patients, ask about access issues (distance to clinic might impair follow-ups). You might plan fewer in-person visits and more phone follow-ups for titrations, or coordinate with community pharmacists in nearer villages for things like BP checks.

Step 3: Intervention – Management Plan and Prescribing

1. Lifestyle Modification for All: Based on the assessment, provide personalized lifestyle advice:

   • Smoking: Strongly encourage quitting. Offer referral to smoking cessation services (or in-practice support if available) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). Document offer and patient response (QOF usually encourages recording smoking cessation advice for smokers).

   • Diet: Advise a heart-healthy diet (rich in vegetables, fruits, whole grains, lean protein, oily fish). Specifically mention reducing salt (to <6g/day) for BP, and saturated fats for cholesterol (Lipid management: Insights from NICE clinical guidelines 2023) (Lipid management: Insights from NICE clinical guidelines 2023). If overweight, discuss weight loss goals (even 5-10% weight loss can improve BP/glucose). Consider referral to a dietitian or structured programs (like NHS Diabetes Prevention Programme or local weight loss schemes) for those with BMI above target.

   • Exercise: Encourage at least 150 minutes/week of moderate exercise (brisk walking, cycling) or equivalent (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). Tailor to the patient’s ability – even chair-based exercises for those with mobility issues. For example, a rural patient could be encouraged to do active farming chores or walking in nature; an urban patient might be directed to local walking groups or gyms with discount schemes.

   • Alcohol: If intake is above guidelines, provide advice on reduction, as alcohol can raise BP and add calories.

   • Education: If diabetic, ensure they’ve had structured education (DESMOND or similar) – if not, offer to refer again. For hypertensive patients, teach them how to monitor BP at home correctly and what readings should prompt contacting the clinic.

   • Use motivational interviewing techniques – rather than just instruct, explore readiness to change and set one or two achievable goals (e.g. “reduce takeaway meals from 3x to 1x per week” or “walk 20 minutes every lunchtime”). Document these goals.

2. Pharmacotherapy – Statins and Lipid Management:

   • Initiating Statins: For any patient with QRISK ≥10% or established disease not on a statin (and no contraindication), recommend starting one ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ) ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ). Explain benefits: “This can lower your chance of heart attack and stroke by about 1/3 over the next decade (How Low Should We Decrease LDL-Cholesterol in a Cost-Effective Manner? - American College of Cardiology).” Address concerns/myths (many patients fear side effects due to media). Use a shared decision approach, but given QOF and NICE expectations, strongly encourage it as the standard of care.

     • First-line: Atorvastatin 20 mg at night for primary prevention (or simvastatin 40 mg if atorva not tolerated, though atorva is preferred). For secondary prevention, use Atorvastatin 80 mg (or highest tolerated dose) (Lipid management: Insights from NICE clinical guidelines 2023) (Lipid management: Insights from NICE clinical guidelines 2023). If the patient is >75, statins are still recommended if they’re likely to tolerate and benefit, although discuss individually (NICE is neutral but allows it).

     • Explain potential side effects (most people tolerate well; <10% get muscle aches, rare serious liver issues). Advise they report any muscle pain, and if so, you will check a CK blood test.

     • Order baseline bloods if not already: LFTs (ALT), non-fasting lipids, ±CK if patient has muscle risk factors. (If recent tests are available from Step 2, use those.)

     • Follow-up plan: Tell them you will recheck liver function and cholesterol in 3 months. Book that follow-up blood test now or place a task for admin to arrange it.

     • Provide a statin information leaflet for reference at home.

   • Titrating/Optimizing Statins: If a patient is already on a statin but not at cholesterol target (e.g. LDL still >2.0 in a CHD patient), increase the dose or intensity:

     • Move from moderate to high intensity: e.g. atorva 10 → 20 mg, or simvastatin 40 → switch to atorvastatin 20 (more potent). According to NICE, high-intensity doses (atorva 20-80 or rosuva 10-40) achieve >40% LDL reduction (Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE) (Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE).

     • If on the highest tolerated dose and LDL still high (especially in secondary prevention), consider adding ezetimibe 10 mg daily. NICE supports ezetimibe as add-on for further reduction (Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE). Ensure to code “ezetimibe prescribed” which QOF accepts as “lipid-lowering therapy” if statin is contraindicated or insufficient (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26).

     • For patients with FH or extremely high cholesterol who don’t meet targets, refer to lipid clinic – newer agents like PCSK9 inhibitors or inclisiran might be indicated and are often initiated in secondary care, but primary care may have protocols (some areas allow GPs to give inclisiran under shared care).

   • Managing Statin Intolerance: If a patient reports muscle aches or other side effects:

     • Stop the statin for a “wash-out” of a few weeks and see if symptoms resolve. Then try a different statin (e.g. switch simvastatin to rosuvastatin, or atorva to prava) (Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE) (Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE).

     • Alternatively, reduce the dose and uptitrate slowly. Even a lower dose gives some benefit.

     • Consider alternate day dosing if daily is not tolerated (off-label, but some patients do this).

     • If truly intolerant to all statins (rare), document this clearly (“Statin contraindication – intolerant”) and consider ezetimibe monotherapy. Also ensure diet and other factors are maximized.

     • Provide reassurance: many perceived statin side effects are not actually caused by the statin (nocebo effect is strong). Encourage retrial if the initial attempt fails, unless side effect was severe.

   • Other Lipid Therapies: Fish oil supplements or fibrates are generally not first-line for CVD prevention (they don’t improve outcomes except in specific scenarios). If triglycerides are very high (>5 mmol/L), you might consider fibrates or fish oil to prevent pancreatitis, but that’s separate from atherosclerotic CVD management. Icosapent ethyl, if available in your formulary and patient fits criteria (CVD + TG 1.7–5.6 & LDL well-controlled), could be added – but this would typically be done in consultation with a lipid specialist. Ensure statin therapy is optimized before considering these.

3. Pharmacotherapy – Blood Pressure Management:

   • Initiating Therapy: If a patient is diagnosed with hypertension (or BP consistently above targets) and not on treatment, initiate an antihypertensive. Base choice on NICE NG136:

     • First-line for <55 years (and not of Black African/Caribbean origin): an ACE inhibitor, e.g. Ramipril 2.5–5 mg (or ARB like losartan if ACE-i not tolerated) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). For those ≥55 or Black patients: a calcium-channel blocker, e.g. Amlodipine 5 mg (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). (If edema or CCB not suitable, a thiazide-like diuretic like indapamide can be used.)

     • Explain to the patient the need for medication: “Your blood pressure is high and medication will help protect your heart and kidneys and prevent strokes.” Many patients feel fine with high BP, so emphasize the preventive aspect. Outline potential side effects to watch (dry cough for ACE-i, ankle swelling for CCB, etc.).

     • Arrange blood test for renal function and electrolytes in ~2 weeks if starting an ACEi/ARB or diuretic (to check for effects on kidney or potassium).

     • Schedule a BP check in ~4 weeks to assess response.

   • Titration: If already on one agent but not at target, follow the stepwise intensification:

     • Step 2: combine ACE-i/ARB + CCB (or + diuretic if CCB not suitable). E.g. add amlodipine to ramipril.

     • Step 3: ACE-i/ARB + CCB + thiazide-like diuretic (e.g. indapamide or chlorthalidone).

     • Step 4: If still uncontrolled (resistant HTN): consider low-dose spironolactone if K+ <4.5, or alpha/beta blocker if not appropriate. Also check adherence and consider specialist referral if truly refractory.

     • With each step, re-check BP in 2–4 weeks and monitor labs as needed (diuretics and spironolactone need periodic U&E checks).

     • Intensify therapy until BP is at goal or max tolerated. Don’t hesitate to use multiple meds; many patients need 2–3 drugs to reach <140/90.

   • Medication adherence: One of the biggest challenges. At each visit, ask non-judgmentally if doses were missed. Simplify regimens where possible (once daily meds, fixed-dose combinations if available). Encourage use of pill boxes or phone reminders. If adherence is suboptimal, more frequent follow-up or involving a pharmacist might help.

   • Use of Home Monitoring: Encourage patients to buy or borrow a home BP monitor (your practice could have a loaner program). Home readings often are lower than clinic; if a patient struggles with clinic measurements, rely on their home log to guide treatment (and you can use an average home reading for QOF documentation if properly recorded in notes as “ABPM/HBPM result”). This can also prevent overtreatment in those with white-coat effect.

   • Special cases: If a patient has specific comorbidities, tailor BP meds: e.g. an AF patient might benefit from a beta-blocker for rate control that also lowers BP; a diabetic with proteinuria should be on an ACE inhibitor for renal protection; an angina patient should be on beta-blocker which helps BP, etc. Leverage these overlaps to streamline therapy.

   • Follow-up frequency: After any med change, follow up in 4 weeks (phone or in-person BP check). Once at target, schedule the next BP check in 6 months (for hypertension) or sooner if clinically indicated. At minimum, as per QOF, ensure annual BP measurement is done and recorded for every hypertension patient (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE).

4. Other Medications: Address all relevant cardio-protective meds:

   • For patients with established CVD (post-MI, stroke, etc.), ensure they are on all indicated therapies: antiplatelet (aspirin or clopidogrel, except in stroke where often both for short term then one long-term), ACE inhibitor, beta-blocker (post-MI or heart failure), and in AF patients, anticoagulation per CHA₂DS₂-VASc score. While QOF specifically emphasizes BP and statin, comprehensive care will improve outcomes and likely simplify achievement (e.g. a well-treated heart failure patient might have better BP control by virtue of being on multiple meds).

   • For diabetic patients, consider if they meet criteria for an SGLT2 inhibitor or GLP-1 agonist as per NICE:

     • If they have CVD or very high risk, and not already on an SGLT2, consider adding (after discussing pros/cons). Many diabetics might already be under specialist care for this, but GPs can initiate as per local protocols. SGLT2i will also aid BP and weight a bit.

     • GLP-1 agonists can be considered if HbA1c is above target on oral meds and BMI >35 or if needing weight loss – while aimed at glycemic control, they incidentally help with weight and modestly with lipids/BP.

   • Atrial Fibrillation (AF): If encountered in a patient during review (e.g. irregular pulse), get an ECG. If AF is confirmed and CHA₂DS₂-VASc ≥2, ensure anticoagulation is offered (this is another QOF indicator, AF007/8). Stroke prevention in AF is part of CVD outcomes improvement (AF strokes are often severe but largely preventable with DOACs).

5. Patient Agreement and Understanding: After formulating the plan, discuss it with the patient to ensure buy-in:

   • Go over any new prescriptions or dose changes. Provide written instructions if multiple changes were made.

   • Ensure they know how to take new meds (e.g. “take in the evening” for statin, or “morning with breakfast” for diuretic to avoid nocturia).

   • Reiterate why each change is important (“This tablet will help protect your kidneys/heart…”).

   • Give them opportunity to ask questions. Encourage them to contact the practice sooner than next scheduled review if they experience problems or if something isn’t clear.

   • If the patient is reluctant about any aspect (say, unsure about starting a statin), explore their concern, provide evidence (maybe show them a chart of risk reduction). If they still decline, respect their decision, code the refusal, but leave the door open: “If you change your mind or have any questions later, let us know. We’ll also revisit this next time to see if you’ve thought more about it.”

   • Document the care plan in the notes and on your disease management template, including targets set (e.g. “aim BP <130/80 due to diabetic nephropathy” if applicable, or note if a higher target accepted due to frailty).

Step 4: Follow-Up and Monitoring

1. Short-Term Follow-up: As arranged, follow up on each intervention:

   • Lab results: When the 3-month statin bloods come back, review them. If ALT has risen but <3x normal, it’s fine to continue; if >3x, consider halving dose or stopping and rechallenge later (Lipid management: Insights from NICE clinical guidelines 2023). Check the lipid levels: calculate % non-HDL reduction or see if LDL goal met. If not, this is a trigger to call patient and intensify therapy or discuss adherence

   • BP checks: If a patient was told to do home readings for a week and send them in, ensure someone reviews those numbers and feeds back. If still above target, make a decision (increase dose or add med) and inform the patient (could do this via phone or text if protocolled: e.g. “Doctor reviewed your home BP readings averaging 155/90 – we need to increase your amlodipine to 10mg, please collect a new prescription. We’ll recheck BP in 4 weeks.”). Make sure this loop is tight so momentum isn’t lost.

   • Missed follow-ups: Use your tracker – if a patient doesn’t go for their blood test or fails to attend a follow-up check, have a system to reach out. Perhaps a nurse phone call to rebook or inquire why.

2. Ongoing Monitoring Schedule:

   • Every 3 months (quarterly): For poorly controlled patients or those actively being titrated, set reminders. E.g. a diabetic with high HbA1c and BP might be seen monthly until stable, then every 3 months to adjust therapy.

   • Every 6 months: Once a patient is at targets, see them biannually or at least call to check in. For example, a blood pressure of 138/88 on last check – you might want to ensure it’s still controlled 6 months later, not wait a full year.

   • Annual Reviews: Ensure a comprehensive review at least yearly for each condition (this can be combined if patient has multiple conditions – e.g. a single annual “CVD review” covering diabetes, BP, cholesterol, etc.). Annual review should include: updated bloods, blood pressure, medication review (any meds to stop or can doses be reduced if risk factor improved?), vaccination status (offer flu, pneumococcal, etc. to those with CVD/diabetes), and any referrals needed (e.g. to retinopathy screening or podiatry).

   • Use a tickler system (alerts in EHR) for tasks like “repeat lipid check in 1 year” or “due cardio review in Oct”. Many systems allow future dated tasks or recalls – utilize these so no one is forgotten.

3. Exception and Safety Netting:

   • After multiple attempts and efforts, some patients will still have readings above target or will not engage. As year-end approaches (or after a certain number of tries), you may decide to exception-report:

   • Criteria to consider exception: patient has been invited 3 times with no response; patient has been seen but persistently refuses intervention despite education; patient is on maximal therapy but still out of range (here you might exception them as “clinical judgement – on max treatment”).

   • Before coding an exception, document in the consultation why: e.g. “BP 150/88 despite on lisinopril 40 + amlodipine 10 + indapamide. Further meds not added due to risk of side effects and patient already dizzy. Will exception-report for QOF BP target this year.” This note justifies to any external assessor why the target wasn’t met.

   • Use the correct Read/SNOMED exception codes (e.g. “BP target not achieved – maximum therapy” or “Patient informed dissent for treatment”). Then enter the exception code in the patient record.

   • Even when excepted, don’t discharge the patient from care – continue to follow-up as needed, just not chasing the QOF target. For instance, a patient who won’t take statins – still check their cholesterol next year and gently bring up the discussion again in future; they might change their mind.

   • Safety-netting: Ensure patients know they can contact the practice if symptoms worsen or if they have issues with meds. For example, if an older patient is started on stronger BP meds, warn them about symptoms of hypotension and advise if they feel faint to let you know (and maybe hold the dose).

   • For any critical values (e.g. extremely high BP or cholesterol) found during the process, have protocols: e.g. BP >180/120 with organ symptoms – same-day referral to hospital per NICE guidelines for malignant hypertension ( Diagnosis and management of hypertension in adults: NICE guideline update 2019 - PMC ); very high cholesterol (e.g. TC >9 or LDL >6) – screen for familial hypercholesterolemia and consider specialist referral.

   • Document any advice given as safety net (e.g. “Advised patient to call if BP >160 at home or any chest pain – will re-evaluate sooner if so”).

4. Coordination of Care: For complex patients, involve other services as needed:

   • If patient has had a recent hospitalization for a CVD event, liaise with cardiology/stroke specialists on the plan (e.g. they might have started new meds – ensure continuity and add to your meds list, arrange any pending investigations like echo).

   • If patient requires it, refer to cardiac rehab (post-MI or heart failure exercise programs) or vascular rehab (post-stroke programs) – these improve outcomes and are often underused.

   • If resource allows, use practice-based health coaches or social prescribers for additional support (they can help with things like finding exercise classes, weight management groups, smoking cessation support beyond what practice can do).

   • PCN roles: Many PCNs now have pharmacists, dietitians, health coaches – integrate them. For example, a pharmacist can do a batch of hypertensive patients’ follow-ups via phone, or a dietitian can see patients with high cholesterol or uncontrolled diabetes for intensive lifestyle counselling.

5. Documentation and Coding at Each Step: Throughout this SOP process, meticulous coding is crucial:

   • Update problem lists with any new diagnoses (e.g. if you diagnose microalbuminuria in a diabetic, code it – it justifies ACEi use).

   • Record numeric values in the correct fields (to count for QOF, BPs must be entered in the BP reading field, not just in free text; same for HbA1c, cholesterol).

   • When goals are achieved, celebrate in notes (“Target achieved: BP now 128/80, well controlled”) – this serves as a clear marker when reviewing later.

   • Use a consistent way to mark that a patient has completed their annual review (some practices add a code or a note like “CVD annual review done – all targets updated”).

   • If a patient is under care elsewhere for an issue (e.g. lipid clinic), annotate that so you know to follow their lead on med changes.

   • Keep a log of outstanding actions for each patient (for example, if a patient needed an uptitration but you decided to defer due to some reason, set a reminder to revisit in a few weeks).

Adapting the SOP for Different Practice Profiles

Every practice has unique challenges; below are modifications to consider for various settings:

Large Urban Practice

Typically has a large, diverse patient list and a broader team. Leverage size by delegating roles – e.g. one nurse focuses on diabetes reviews, another on hypertension. Use technology extensively: automated text recalls, patient online access for booking reviews, maybe kiosks in waiting room for BP measurements. Urban populations may have language diversity – consider multilingual health educators or translated materials. High list turnover is common (patients moving in/out): run more frequent searches for new patients who might need CVD risk assessment on registration. Partner with local community programs (city fitness initiatives, healthy cooking classes) for referrals. Large practices might run “one-stop” clinics (e.g. blood test, BP, and nurse consult in one visit) to accommodate working-age patients who find multiple visits difficult. Also, more staff means you can hold quality improvement meetings regularly – use data to identify gaps in care among sub-populations (e.g. if you notice a particular ethnic group has lower statin uptake, brainstorm targeted interventions such as a community talk or faith-based outreach).

Small Rural Practice

Likely has fewer staff and a tight-knit patient population. Personal knowledge of patients is an asset – staff often know families and can tailor advice knowing the context (e.g. farming lifestyle, long travel distances). Here, accessibility is a big factor: bring care closer to patients whenever possible. For instance, collaborate with district nurses to check BPs or take bloods during home visits for housebound patients. If patients live far, cluster appointments (e.g. do family members’ reviews on the same day to reduce trips). Consider dispensing practice advantages – you see patients when they pick up meds, use that touchpoint for quick checks (“let’s quickly check your BP while you’re here for your prescription”). In a small team, cross-train staff: a single nurse might do both diabetes and hypertension clinics. Use telephone reviews creatively to supplement in-person (rural patients may prefer not driving in for minor adjustments). Build community support: perhaps start a local walking group or work with a local charity to host education sessions (people might trust advice more in a community hall than a clinic). Internet connectivity can be an issue in remote areas, so don’t rely solely on digital communications – old-fashioned letters or phone calls might reach patients better.

Deprived Community Practice:

Patients may face socioeconomic hardships, low health literacy, and competing life priorities. To improve engagement:

• Outreach and Trust-building: Work with local community health workers or link workers who can connect with patients outside the surgery. They might visit patients at home or meet them in community centers to encourage attending health checks.

• Flexible access: Offer walk-in clinic times or extended hours (early morning/evening) for those who may have unstable jobs or difficulties keeping scheduled appointments. Possibly align CVD review invites with other events (e.g. many deprived-area practices have high DNA rates, but if you offer health checks during flu jab clinics or when patients come for something else, you catch opportunistically).

• Simplify communication: Use phone calls more than letters (letters may not be read or addresses may change frequently). When calling, staff should be empathetic and stress benefits (“We’re concerned because your blood pressure is high, but we can help you with that. This check is free and important for your health”). Offer incentives if feasible (some areas give free fruit baskets or entry into raffles for attending check-ups – small nudges can help).

• Address barriers: If cost of prescriptions is an issue, ensure patients know about the prepayment certificate or benefits that cover costs. If transport is an issue, see if local volunteer services provide rides to clinic.

• Community partnerships: Partner with local charities, shelters, or religious institutions. For example, set up a blood pressure station at a church on Sunday or a pop-up clinic at a community fair. Bringing care to where people are can capture those who don’t come to the surgery.

• Education and empowerment: Use simple language and relatable examples. Rather than “You have a 30% 10-year risk of CVD,” say “Out of 10 people like you, 3 might have a heart attack in the next years – we want to reduce that number for you.” Visual aids showing clogged arteries vs healthy arteries, or sugar content in foods, can leave an impact.

• Recognize social issues (homelessness, mental health issues, addiction) that might underlie poor risk factor control. Link with social prescribing or support services as part of the plan (e.g. help patient get into a rehab program or housing support – indirectly, stabilizing these issues can free the patient to care about their BP and meds).

Other Profiles (if applicable):

• High proportion of elderly/frail: Focus on individualized targets, avoid overtreatment – your SOP might include a step to assess frailty for every >75 patient and then decide if QOF targets are appropriate or if they should be exception due to frailty. More frequent home visits or telephone checks instead of requiring clinic visits.

• University campus practice (young population): Likely fewer chronic diseases but could do opportunistic risk screening (e.g. BP and obesity checks at registration, lifestyle counseling to prevent future CVD). Not a major QOF driver since few will qualify for those indicators, but planting prevention seeds early is worthwhile.

Each practice should adjust the above steps to its reality, but the core remains: identify all who need care, make a plan for each, and use the whole practice team and community resources to execute it. Regularly reviewing outcomes and adapting the approach will ensure the SOP remains effective across different practice contexts.

Best-Practice Focus Areas

The following are specific best practices integrated in the SOP, highlighted here for emphasis:

Statin Prescribing & Lipid Management

Use high-intensity statins per NICE – e.g. atorvastatin 20–80 mg is first-line for most (Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE) (Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE). Always check baseline lipids and LFT, and re-check 3 months after starting or changing dose (Lipid management: Insights from NICE clinical guidelines 2023) (Lipid management: Insights from NICE clinical guidelines 2023). Aim for ≥40% reduction in non-HDL cholesterol from baseline; if not achieved, address adherence then uptitrate or add ezetimibe (Lipid management: Insights from NICE clinical guidelines 2023) (Lipid management: Insights from NICE clinical guidelines 2023). In secondary prevention, push for LDL ≤2.0 mmol/L if possible (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26) – this may mean maximal statin dose and combination therapy. Encourage long-term adherence: one method is scheduling annual “cholesterol review” where you share progress (e.g. “your LDL was 3.5, now it’s 1.8 – fantastic, this is protecting you”). That reinforces to the patient why the pill is important. Be aware of drug interactions with statins (e.g. amlodipine with simvastatin requires max 20 mg simva, certain antibiotics like clarithromycin require holding simvastatin/atorva during treatment). Use tools like patient decision aids if someone is unsure about starting a statin – these tools from NICE can help weigh pros/cons in an unbiased way.

Blood Pressure Monitoring & Control

Ensure BP is measured accurately – staff should have refresher training on technique (seated, rested, arm supported, correct cuff) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE). Validate home monitors if patients use them (many practices ask patients to bring their machine in once to compare with clinic device). Promote home monitoring – it empowers patients and provides more data; many people enjoy seeing their improvements. When adjusting BP meds, do one change at a time (so you know what worked or if side effect happens you know the cause) unless BP is very high and urgent action needed. Utilize clinic protocols: for example, a nurse-led titration clinic where nurses follow an algorithm can achieve control faster than waiting for GP appointments. Involve patients in goal-setting: some like a target to hit (“let’s try to get your BP to 130/80 by your next diabetes review”). Celebrate improvements even if not at target yet (“great, you dropped 10 points, that’s progress, keep taking your meds and we’ll aim for the rest”). Always keep patient safety in mind: for an older person or someone with autonomic neuropathy, check for orthostatic hypotension – measure BP lying/sitting and then standing (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE) (Recommendations | Hypertension in adults: diagnosis and management  | Guidance | NICE); if a big drop, maintain them at a slightly higher BP to avoid falls, and note this plan (exception report if needed with reason). Document home readings in the medical record – either as a patient-entered diary via online portal or scanned copy – they count if clearly dated and averaged.

Patient Safety in CVD Management

Safety considerations include:

• Regular blood monitoring for certain meds: e.g. U&E 1–2 weeks after starting ACEi/diuretic, then periodically; LFT with statins as noted.

• Watch for potential drug adverse combinations: if patient on an ACEi + diuretic + NSAID (common “triple whammy”), counsel to avoid NSAIDs due to kidney risk. If on amlodipine, avoid high-dose simvastatin. Adjust warfarin if starting/stopping statins or amiodarone (if you still have warfarin patients).

• Frail or elderly patients: de-intensify therapy if needed. It’s acceptable to run slightly higher BP or cholesterol in someone with limited life expectancy or multiple falls – use clinical judgment and involve them in decisions. QOF allows excluding patients with severe frailty from some indicators (e.g. DM036 excludes those coded with frailty) (NHS England » Changes to the GP Contract in 2025/26).

• Polypharmacy reviews: Many CVD patients end up on 8-10 medications. Conduct annual polypharmacy reviews (perhaps with a pharmacist) focusing on whether each med is still indicated, and checking renal function for dose appropriateness. For example, an older patient’s diuretic dose might be cut down if their BP is well controlled and they had hyponatremia.

• Clear communication: when you make medication changes, especially multiple, write it down for the patient or use patient-held booklets (BP passport, etc.). This reduces confusion that can lead to errors (like double dosing).

• Allergy/Intolerance coding: If a patient has a true allergy or serious adverse reaction (angioedema with ACEi, for instance), code it as an allergy in the record to prevent re-prescribing accidentally.

• Continuity for high-risk patients: Where possible, have the same clinician or small team follow a complex CVD patient through the cycle – they will know the history and catch subtleties (like patient not telling another GP they stopped a medication). If your practice offers personal lists or usual doctor/nurse, use that for these conditions.

Exception Reporting (Patient “Opt-Outs”)

Use exception codes in a patient-centered way. The intention is to avoid penalizing practices when guideline-driven treatments are inappropriate or refused, not to exclude patients for convenience. Best practices:

• Only exception-report after making a genuine effort to achieve the indicator (unless an obvious exception applies, like patient is terminally ill – then you can exception upfront).

• Inform patients (implicitly or explicitly) when they are being excepted. E.g. if a patient says “I absolutely won’t take a statin,” you can say “Okay, I’ll note that in your records so we won’t keep asking you about it every time – but if you change your mind we can restart it.”

• Keep a list of all exceptions and review them periodically. Sometimes you might retry later – e.g. a patient who declined a statin one year might be more willing after their friend has a heart attack or after you show their cholesterol is higher. Particularly for diabetic patients <40 who might have been excepted due to low initial risk – once they age into risk or have duration >10 years, revisit statin discussion.

• Do not exception-report en masse at year-end without individual consideration – this can lead to suboptimal care. Each exception ideally has a clinical rationale documented.

• Watch exception patterns: if one GP is excepting a lot of patients for “patient refusal,” perhaps that GP’s consultation approach could be adjusted to improve patient acceptance. Or if many are excepted for “max tolerated therapy,” perhaps more creative med regimes could be tried or a specialist opinion sought.

• Finally, ensure exceptions are coded before QOF year-end and codes are QOF-recognized. Do not use free text to note exceptions – it won’t count. Use the structured codes (e.g. “Medication contraindicated” or specific exception codes).

By adhering to this SOP and its embedded best practices, the practice can create a cycle of continuous CVD care: identify risks, intervene effectively, follow up diligently, and adjust as needed. Over time, this should lead to improved patient outcomes (fewer heart attacks, strokes, better quality of life) and high performance on QOF indicators, which in turn supports the practice’s income and sustainability.

Implementation Timeline (2025/26)

To ensure the above strategies are executed without overwhelming the practice, a phased implementation timeline is recommended. Here is a month-by-month/quarter-by-quarter schedule for the QOF year (April 2025 to March 2026), with attention to peak workload periods:

Q1 (Apr – Jun 2025): Planning and Early Action

• April 2025:

  • Launch Meeting: Hold a team meeting early April to brief all staff on the new QOF CVD changes and targets. Assign roles (e.g. Dr X leads hypertension, Nurse Y leads diabetes, Pharmacist handles med reviews). Set internal goals (e.g. “By December, we aim to have 80% of our hypertension patients to target”).

  • Data Clean-up: In the first 2 weeks, run the searches to update registers and identify target cohorts (per SOP Step 1). Divide up lists among team members.

  • Contact High-Risk Patients: Immediately reach out to the highest risk uncontrolled patients – e.g. those with very high BP (>170/100) or recent stroke patients needing follow-up. April is a good time for intensive outreach before the Easter break. Also invite patients who were exception-reported last year for review – perhaps circumstances changed.

  • Templates & Tools: By mid-April, ensure all your EMR templates and call-recall systems are updated for the new QOF indicators. If using any new codes (like DM036 instead of DM033), make sure templates reflect that.

  • Quick Wins: April is also year-end for previous QOF – you’ll know by now where gaps were. If any patients just missed last year’s targets, prioritize them now (e.g. someone with BP 142/92 – get them in and controlled early).

• May 2025:

  • Commence Structured Recalls: Start with disease area that has largest volume – often hypertension or diabetes. For example, send out invites to all hypertension patients due for review who haven’t been seen in 6+ months. Also schedule annual reviews for all CHD and stroke patients in May/June (since these are often fewer in number than diabetics but high priority).

  • Run Hypertension Clinic Blitz: In May, consider running a special “BP control month”. Nurses or HCAs can offer blood pressure drop-in clinics twice a week for quick checks and adjustments. Market it to patients (“May is Blood Pressure Check Month – walk in to get yours checked!”). This identifies uncontrolled folks who might not schedule on their own.

  • Staff Training: Provide a short refresher training for staff on taking BP measurements accurately and using home BP kits, perhaps delivered by a practice nurse or local specialist. Also train on any new protocol (e.g. how to do standing BP or how to use a new EMIS template).

  • PCN Collaboration: Check with your Primary Care Network if any CVD initiatives are starting this quarter. Align your efforts (e.g. if PCN has a CVD project, integrate it with your plan and maybe get extra resource for May/June).

• June 2025:

  • Diabetes Focus: With QOF bloods often done after end of QOF year, many diabetics may be due mid-year checks. Use June to recall diabetic patients (especially those with high HbA1c or BP last visit) for an interim review. Also, ensure all diabetics >=40 are on statins or have an exception code by now – a quick search “diabetic >40, no statin coded” can generate a call list to address this gap early (NHS England » Changes to the GP Contract in 2025/26) (NHS England » Changes to the GP Contract in 2025/26).

  • Mid-Q1 Review: End of June, evaluate progress. How many hypertensives have been seen? Are cholesterol checks being done? Use a sample of QOF reports to see if indicators moved (there might not be big jumps yet, but ensure processes are flowing). Address any backlog – e.g. if invite response was low, plan a different approach (maybe more phone calls).

  • Exception Prep: Identify patients who might require exception (like truly non-responders or those who moved away) and mark to attempt a final contact later in year. But don’t code exceptions yet – just note potential ones.

Q2 (Jul – Sep 2025): Execution and Outreach

• July 2025:

  • Summertime Push: Early July, continue recalling patients but be mindful of staff and patient holidays. Try to wrap up as many routine reviews as possible by late July before holiday season peaks. Particularly aim to see remaining CHD, stroke, and CKD patients in July – these registers are smaller, so ideally by end of July almost all such patients have had a review or at least an appointment scheduled.

  • Clinical Audits: Conduct a mini-audit of a few complex cases: e.g. randomly pick 5 patients with uncontrolled BP and review their management – are we following up timely, are there any barriers? Use findings to tweak processes (maybe you discover a lot of patients didn’t pick up their new BP med – then involve pharmacists to do follow-up calls after new med prescriptions).

  • Patient Engagement: Consider a patient education event this month (if feasible, perhaps an evening talk at the practice or a local community center). Topic could be “How to reduce your risk of heart attack and stroke.” Invite patients with high risk (could send SMS invites). Use this forum to educate about diet, exercise, and to promote acceptance of therapies like statins. Engaged patients may become more compliant. Summer weather might allow an outdoor “health fair” with BP checks as well.

• August 2025:

  • Maintain Effort with Flexibility: August is often slower due to holidays. Anticipate lower attendance; still, keep the engine running:

    • Offer limited but key clinics (perhaps fewer clinics if staff away, but don’t stop entirely). Ensure cover for monitoring blood results and critical tasks even if key staff are off.

    • Use this time for data maintenance: update problem codes, clear out duplicate entries, summarize care plans in records. This behind-the-scenes tidying will pay off when the pace picks up again.

    • Prepare for Autumn: Order any needed equipment for upcoming months (e.g. additional home BP monitors if you plan to lend out during winter, or printed patient education leaflets to hand out at flu clinics).

    • Staff cross-cover: If a lead nurse is on leave, ensure someone else checks her pending tasks for follow-ups so nothing waits a month.

  • Targeted Calls: Late August, start phoning patients who have not responded to earlier invites. Especially focus on those with the worst control who haven’t come in – use a friendly personal call to stress importance and flexibility in scheduling. Sometimes August works for teachers or those who get summer off – they might attend now if reached.

• September 2025:

  • Gear Up for Autumn: In September, patient contact with healthcare generally rises again. Use this to your advantage:

    • Plan to complete any remaining annual reviews for CVD conditions by end of September (except diabetics, who often have two reviews/year – one could be now). By now, ideally all patients on CHD, Stroke, Hypertension, CKD registers have had at least one contact in 2025.

    • Flu Clinic Integration: Flu season preparations begin. Liaise with whoever runs your flu clinics (often starting late Sept or early Oct) to integrate CVD checks. For example, at flu jab appointments, have HCAs ready to do a quick BP check or hand the patient a card saying “Book your annual heart health check if not done.”

    • Review Interim Metrics: Pull QOF report end of September. See current achievement: perhaps BP control is at 70% and you need to get to 85%. Identify which patients are driving that gap (the 15% uncontrolled). Start listing those for intensive management next quarter.

    • PCN / ICB Reporting: Some networks might ask for mid-year performance. Have your data ready to share good news or request help if needed (e.g. “We achieved X% statin uptake but struggling with BP in mental health patients” – maybe a solution can be found collaboratively).

    • Team Check-in: Meet with staff to celebrate successes so far and highlight areas needing more work. E.g. “Great job, 200 patients started on statins! But only half of our stroke patients hit the BP target – let’s focus on them.” Re-motivate before winter pressures.

Q3 (Oct – Dec 2025): Intensification and Catch-up

• October 2025:

  • Flu Clinics = CVD Opportunities: Leverage high patient footfall during flu vaccination clinics (usually many in October). Implement a system: while patients wait post-jab, staff can quickly do BP or hand out CVD risk pamphlets. Perhaps stamp charts of those who need a blood test (“Mrs. Smith needs bloods – please go next door after flu shot”). This piggy-backing can capture patients who avoided dedicated chronic appointments.

  • Focus on Diabetes: Q3 is a common time for diabetic annual reviews (after summer indulgences and before holidays). Ensure all diabetics have their QOF care processes done by end of October: foot exam, retinal screening referral updated, microalbumin test done, etc. Intensify treatment for those above targets so that by year-end they improve. Also, double-check statin prescribing in diabetes: by now, very few (if any) diabetics >40 should be without a statin or exception code – if there are stragglers, address immediately.

  • BP Sprint: As weather cools, BP tends to rise (vasoconstriction in cold months). It’s wise to re-check controlled hypertensives in Oct/Nov to catch any upward drift. Call in those who were borderline controlled in summer for a BP check. Adjust meds as needed before winter fully hits.

  • Exception Review: Start a preliminary list of who might be exception-reported if still uncontrolled by Jan. For example, an elderly stroke patient on maximal meds who is at 150/90 might be one. Don’t code it yet, but note to discuss at year-end if not improved. Also, anyone who still hasn’t responded to any invites – plan one more robust attempt (perhaps a GP letter or phone call) before labeling as exception.

• November 2025:

  • Year-End Rush Planning: November can be busy with viral illnesses, but it’s crucial for QOF to make big gains now, as December is often disrupted.

  • Early Nov: do a penultimate QOF progress check. Identify every indicator that’s below the ideal trajectory. For each, list the patients who are not meeting it. Assign responsibility: e.g. Nurse A will tackle 10 highest BP diabetics, Pharmacist will call all patients with LDL >2.5 on last check to intensify statin.

  • Intensive Clinics: Consider dedicating certain days as “QOF catch-up clinics.” For example, one Saturday flu clinic could be turned into a combined flu+CVD clinic inviting those who need both (some practices run a “Pulse and Pressure” clinic with flu – checking AF and BP along with shots). Or add early/late sessions midweek for those who couldn’t come during 9-5.

  • Peak Exceptions Contact: By end of November, for any patient you think you’ll have to exception because they haven’t engaged, make one last personal contact attempt. Ideally by a GP or senior nurse – a frank phone conversation or letter explaining the health importance and that you respect their choice but want to offer once more. Sometimes this triggers a response (“okay I’ll come in”). If not, you have documentation that you tried.

  • Staffing Prep for Dec/Jan: Ensure cover is arranged for the upcoming holiday period – who will handle urgent lab results, who will follow up if someone’s in the middle of titration. Try to avoid starting very fragile patients on new therapies right before holidays (unless necessary) as monitoring is harder when staff are out.

• December 2025:

  • Wrap-up Critical Actions: Early December, push to complete any remaining tasks. If a patient needs one more blood test to confirm improvement (like a December cholesterol test to see if that LDL came under 2 for CHOL004), get it done by mid-Dec before labs and patients become unavailable.

  • QOF Data Cleaning: Use the quieter last half of December (when many routine patients postpone appointments) to do data cleaning: ensure all QOF codes have been correctly entered. E.g., check that all patients on the CHD register actually have a BP recorded in 2025 – if not, maybe someone slipped through, and try to get them in last minute or exception code if not feasible.

  • Exception Coding (First Round): For patients you are certain belong as exceptions (e.g. those in nursing homes, hospice, or repeatedly refusing), you may enter exception codes in December so as not to forget in the January rush. (Be cautious to not exception too many too early; but truly justified ones can be done now – such as a patient who moved abroad or a frail 95-year-old with multiple falls where you’re not chasing BP).

  • Celebrate and Motivate: Acknowledge the team’s hard work so far. Share any improvements seen (e.g., “we’ve lowered our average practice BP by 5 mmHg, that’s great for patients!”). This boosts morale for the final stretch and reminds everyone that these numbers have life-saving implications, not just bureaucratic targets.

Q4 (Jan – Mar 2026): Final Optimisation and Audit

• January 2026:

  • New Year Re-engagement: The first two weeks of January can be slow as patients recuperate from holidays, but also a time of resolutions. Capitalize on that – some patients are more receptive to health advice now. Send a cheerful message (“Happy New Year! Let’s make 2026 a heart-healthy year – if you haven’t had your blood pressure/cholesterol check recently, contact us.”).

  • Final QOF Review Meeting: First week of Jan, convene the team to review QOF status. At this point, identify any remaining gaps to target. For example, you might see your CHOL004 (cholesterol ≤2.0) is at 45% and you need 50%. That tells you to find a handful of patients just above target and intensify their therapy or do re-tests. Make a checklist of actions needed per indicator.

  • Mop-Up Clinics: January should be used to see any patients who were scheduled in Dec but missed due to the holidays or illness. Aim to get all these “January backlog” patients seen by end of the month. Also, continue seeing follow-ups for med adjustments done in Nov/Dec.

  • Data Validation: Double-check that all newly diagnosed patients from the year have been coded on registers (sometimes a diagnosis made in say, October might not have been added to the QOF register code – fix that now so they’re counted).

  • Documentation for Exceptions: For any patients you anticipate exception coding in March, ensure their documentation is up to date now. E.g. if you plan to exception “patient declined statin,” make sure there’s a consultation note saying “discussed statin, patient declined on [date].” This way, if any queries or peer reviews happen, you have contemporaneous reasoning.

• February 2026:

  • Intensive Last Mile: February is the crunch time to chase the last few points. At start of Feb, identify each indicator where you haven’t hit the upper threshold yet. List the patients holding it back:

    • For BP indicators, maybe only 10–20 patients remain uncontrolled. Bring all of them in if possible this month. Even one extra patient controlled can yield several points if it moves you into the next threshold bracket.

    • For cholesterol, see who hasn’t had a recent test. If someone was started on a statin in November, get their 3-month test now – perhaps they hit target which will count.

    • For statin prescribing (CHOL003, DM034/35), ensure any patient who could be on a statin is either on it or has an exception by now. February is a good time to finalize those who truly won’t start – code the exception in late Feb.

  • Exception Coding (Final Round): In the latter half of Feb, enter exception codes for those who have not responded or who are inappropriate to treat. E.g. mark the few who refused to come despite multiple invites (“interp refusal”) or those with contraindications. This helps your QOF % because by removing them from denominator, your achievement % rises. Be careful to not exception so many that you underachieve actual care – focus on those necessary.

  • Clinical Safety Check: As you adjust treatments aggressively in pursuit of targets, double-check no one is at risk: e.g. if you pushed several patients’ BP meds, ensure none have hypotension symptoms unaddressed. If a patient’s blood sugar was pushed down, ensure no hypoglycemia issues. The drive for QOF should not compromise patient safety – usually it aligns with good care, but always verify.

  • Coding Audit: Have one team member do a random audit in Feb: pick 5–10 patients per indicator who are marked as achieved, to ensure all coding is correct (e.g. the cholesterol value was indeed in current period, etc.). This is to catch any mistakes while there’s still time to fix (for instance, discovering a batch of BPs were entered with wrong date or an interface issue – better to find out in Feb than after March).

• March 2026:

  • Final Data Capture: First two weeks of March are about capturing any stragglers:

    • Do a last call for patients who could still improve with one change – e.g. a hypertensive patient comes in early March, you increase a med, and have them return end of March for a BP check – that reading can count if before March 31. Similarly, chase the last cholesterol tests by mid-March to have results back.

    • Ensure all specialist letters that might impact QOF are summarized in records. If a cardiologist letter from February says “BP 130/80 in clinic” or “Started rosuvastatin 40 mg,” record that BP in the structured field and update meds – it counts for QOF if in record. Often end-of-year, GPs forget to code values from hospital notes – don’t miss those opportunities.

    • Immunization indicator note: (Though not directly CVD, if any vax indicators exist, flu etc., ensure done by March).

  • Lockdown Data: Around the third week of March, aim to have essentially everything done. Use the last 7–10 days for final verification and correcting any data errors. Check QOF calculation reports for any red flags (like patients appearing in denominator who shouldn’t, or vice versa).

  • Submit QOF & Review: End of March (usually 31st or early April), QOF data will be extracted or submitted. Ensure all entries are in by 31st March 23:59. Print/save a copy of your QOF achievement for records.

  • Team Debrief: Have an informal debrief or small celebration. Acknowledge the team’s efforts for the year – e.g. share how many strokes or MIs potentially prevented by the improved risk factor control (this can be estimated from known stats: “We started statins in 100 new high-risk patients; that might prevent ~10 heart attacks in the next 10 years (How Low Should We Decrease LDL-Cholesterol in a Cost-Effective Manner? - American College of Cardiology) – lives literally saved!”). This helps reinforce the value of the work beyond the financial aspect.

  • Carry Forward Planning: Make notes of what worked well and what didn’t in the implementation. For instance, if telephone reviews in August were low yield, plan differently for next year. If a new EMIS template made things easier, ensure to use it consistently. This reflective practice ensures continuous improvement in how the practice handles QOF and patient care year on year.

In summary, this timeline staggers the workload: heavier in Q1 (setup and high-risk cases), steady in Q2 (continuing reviews), big push in Q3 (utilizing flu season and before winter ends), and final tuning in Q4. It also aligns with natural healthcare cycles (flu season, holidays). Flexibility is key – if an unexpected event occurs (e.g. a COVID surge or staff shortages), adjust by maybe deferring some routine work and doing a double effort in the following months. By following a planned calendar, the practice avoids the panic of last-minute QOF chasing and ensures quality care is delivered consistently throughout the year.