The 2025/26 Network Contract DES has put a sharp focus on cardiovascular disease (CVD) prevention, with new QOF indicators that directly impact practice income. The NHS Long-term plan identified CVD as a clinical priority and “the single biggest condition where lives can be saved over the next 10 years” (NHS, 2019).
- CVD affects approximately 7m people in the UK
- Causes 1 in 4 premature deaths
- Number one cause of death in deprived areas
- Disproportionately affects people with severe mental illness – 83% higher risk of death from CVD
Given these startling statistics and its impact on health inequalities, it’s easy to see why CVD prevention has taken centre stage as we move towards meeting the 3 key aims of the 10-year plan:
- Shifting care into the community
- Focusing on prevention
- Analogue to digital
The new 2025/26 QOF indicators – what’s changed?
32 QOF indicators totalling 212 QOF points and worth £298m to practices in 2025/26 have been permanently retired and redistributed. 71 QOF points (approx £100m) has been put directly into the global sum, however the majority has been invested into CVD prevention and proactive care. For an average practice, the new CVD QOF payments totals approximately £49,950 based on an average payment of £225 per QOF point, with 222 CVD QOF points available. If you take into account all CVD- and diabetes-related indicators for 2025/26, it now totals 333 (76%) of the QOF points available, demonstrating the commitment to prevention and improving long-term conditions management in primary care. Achieving these NHS targets amounts to a potential income of £76,088 per year for an average GP practice.
I recently attended an excellent primary care event “PCN Plus Live” which brought PCN leaders together to discuss best practice and evaluate the recent release of the DES 25/26. It was highlighted that without a significant shift in how they support patients with long-term conditions, the majority of practices will not meet the new CVD targets and will miss out on considerable income in 2025/26.
Why are practices struggling?
People living with CVD or other long-term conditions often are frequent attenders, responsible for almost half of all GP appointments, and seeing the GP on average 5 times more than the general population (Kontopantelis, 2021). Attendances are often for medication changes, social or mental health problems, seeking reassurance, and the complexities of managing often multiple comorbidities. With 10-minute appointments, and stretched resources in primary care, GPs are struggling to have the impact they would like on people living with CVD and other long-term conditions.
The new QOF indicators don’t just call for practices to prioritise CVD patients, they have also made targets harder to achieve, calling for improved outcomes for people living with CVD to minimise the risk of further complications. The lower thresholds remain achievable; however the higher thresholds have jumped from between 70-75% to 90% in many cases – meaning nearly all patients need to be meeting the target blood pressure and cholesterol measurements to avoid missing out on QOF payments (see QOF CVD summary). This represents a significant shift towards focusing QOF on quality, proactive, preventative care.
What’s the best way to tackle CVD and meet QOF targets?
Medications will continue to play a vital role in preventing further complications in people with cardiovascular diseases, and the QOF indicators highlight the need for as many patients as possible to be on the correct medications. But does it stop there? Patients need to have good medication adherence to ensure the target blood pressure, cholesterol, and HBA1C levels are achieved – this may require supported self-management.
Medications aren’t always the preferred choice for patients either, especially given the potential side effects of medications such as statins that are so well publicised. For many patients, making positive lifestyle choices will be the preferable option, not only to improve their cardiovascular and metabolic health, but to feel more energised and live healthier, happier lives. Lifestyle changes consistently show reductions in blood pressure and cholesterol, whether it’s through dietary changes, increasing activity, reducing stress, increasing time outdoors and social interactions. NICE guidance (2023) highlights the importance of lifestyle interventions in CVD prevention, focusing on 5 key factors for primary and secondary prevention:
- A cardioprotective diet
- Physical activity
- Weight management
- Reduced alcohol consumption
- Smoking cessation
We also know that living a healthy lifestyle will help to minimise the risk of many other co-morbidities – from diabetes, obesity, osteoarthritis, right through to COPD and Cancer. This is a great opportunity to not only improve CVD outcomes, but tackle the many other health problems driving the health crisis in the UK and beyond.
There is a growing understanding of the importance of a healthy lifestyle, but lifestyle change is not always easy – and advice alone rarely achieves lasting behaviour change. Lifestyle and behaviour changes need structured support, education, time, and a programme to understand how lifestyle changes will allow them to live longer and healthier lives. Changing behaviour can be tough, and guidance from trained professionals with the right resources is vital. Structured supported self-management needs to address the key driving factors of CVD and other chronic health conditions, utilising behaviour change strategies and motivational interviewing to achieve lasting change.
What ARRS roles can we utilise to achieve the best outcomes?
Since 2019 and the introduction of key ARRS personalised care roles, we have seen a variety of ARRS roles introduced into primary care, including Physiotherapists, Paramedics, Social Prescribers, Pharmacists, and Health and Wellbeing Coaches. The evidence supporting these roles in reducing GP workload is growing rapidly, and getting the most from these roles may be the most efficient way to achieve the best outcomes. Health and Wellbeing Coaches (HWCs) are having more and more of an impact throughout the country as PCNs start to realise the potential of these roles. Funded through ARRS and recommended by the NHS as a key supported self-management role, they are specifically trained to work with patients to:
- Help patients to understand CVD and empower them to take control
- Set realistic goals
- Support behaviour changes over time through motivational interviewing and behaviour change strategies
- Address barriers like low confidence or health literacy
- Sustain lifestyle changes that drive improvements in CVD outcomes
The evidence is clear that health coaching and healthy lifestyle choices is extremely effective at improving clinical outcomes for people living with long-term conditions (Boehmer et al 2023). A recent systematic review demonstrated health coaching can reduce blood pressure, improve dietary behaviours, and increase self-efficacy among patients with hypertension (Meng et al, 2022).
Other ARRS roles can also play a key part in this drive for improved CVD prevention, with pharmacists well placed to ensure patients are on the appropriate medications and keep track of the medications. Social prescribing link workers can improve patients’ engagement with their community and activity levels, linking them with local groups and services. Integrated neighbourhood teams and specialist long-term conditions services proactively targeting CVD prevention will see the biggest success, with practices collaborating and utilising PCN ARRS roles to achieve QOF targets.
Achieving the best outcomes and impact for primary care teams
Developing proactive, preventative services in primary care targeting long-term conditions aligns with this NHS 10-year plan 3 key aims and will have a huge positive impact on member practices and the PCN team.
Innovative services will help to:
- Meet QOF targets and generate up to £75,088 per practice
- Reduce pressures on GPs – improving self-efficacy and reducing the need for regular follow-up checks
- Improve medication adherence
- Offer patient choice and high patient satisfaction
- Demonstrate alignment to the 3 key aims of the 10-year plan
We await further direction from the 10-year plan, but the DES 25/26 and the new QOF indicators give a clear direction to primary care that CVD and diabetes prevention needs to be right at the top of PCNs and practices priorities. PCNs have a great opportunity now to start services that support their practices to meet QOF targets, reduce pressure on clinical teams, improve patient satisfaction, and ultimately save lives.
Learn more about our Long-Term Chronic Conditions Support Service
Adam Davies, Health & Wellbeing Services Lead
After a series of knee injuries brought a premature end to a promising football career, Adam redirected his passion for movement and recovery into physiotherapy. He graduated from Salford University and gained extensive NHS experience at the Royal London Hospital and Barts Health NHS Trust, before specialising in musculoskeletal (MSK) physiotherapy.
With a particular interest in chronic pain and the biopsychosocial approach, Adam built his expertise across NHS services, private practice, and sports settings. In 2017, he became part of one of the first pilot programmes for First Contact Physiotherapy (FCP), completing the inaugural FCP in Primary Care module at the University of Central Lancashire. He went on to spend three years as an FCP at Rotherham NHS Foundation Trust.
Adam later moved into a regional leadership role with Pure Unity Health, where he led FCP and MSK services across Yorkshire and the North East for four years. He now leads the organisation’s Health and Wellbeing Services, focusing on proactive, preventative care for people living with chronic pain and long-term conditions.
Adam is passionate about driving innovative models of care that support NHS priorities—especially prevention, personalised care, and reducing health inequalities in line with the 10-year plan.
References
- National Institute for Health and Care Excellence (2010). Overview | Cardiovascular disease prevention | Guidance | NICE. [online] Nice.org.uk. Available at: https://www.nice.org.uk/guidance/PH25
- National Institute for Health and Care Excellence (2019). Recommendations | Hypertension in adults: diagnosis and management | Guidance | NICE. [online] Nice.org.uk. Available at: https://www.nice.org.uk/guidance/ng136/chapter/Recommendations#treating-and-monitoring-hypertension.
- NHS England (2025). Quality and Outcomes Framework guidance for 2025/26. Publication reference: PRN01904 Classification: Official. [online] Available at: https://www.england.nhs.uk/wp-content/uploads/2025/03/quality-outcomes-framework-guidance-for-2025-26.pdf
- Kontopantelis E, Panagioti M, Farragher T, Munford LA, Parisi R, Planner C, Spooner S, Tse A, Ashcroft DM, Esmail A. Consultation patterns and frequent attenders in UK primary care from 2000 to 2019: a retrospective cohort analysis of consultation events across 845 general practices. BMJ Open. 2021 Dec 20;11(12):e054666. doi: 10.1136/bmjopen-2021-054666. PMID: 34930742; PMCID: PMC8718478. https://pubmed.ncbi.nlm.nih.gov/34930742/
- Kasey R. Boehmer, Neri A. Álvarez-Villalobos, Suzette Barakat, Humberto de Leon-Gutierrez, Fernando G. Ruiz-Hernandez, Gabriela G. Elizondo-Omaña, Héctor Vaquera-Alfaro, Sangwoo Ahn, Gabriela Spencer-Bonilla, Michael R. Gionfriddo, Juan M. Millan-Alanis, Marwan Abdelrahim, Larry J. Prokop, M. Hassan Murad, Zhen Wang, The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis, Patient Education and Counseling, Volume 117, 2023, 107975, ISSN 0738-3991, https://doi.org/10.1016/j.pec.2023.107975
- Fei Meng, Yunxia Jiang, Pengli Yu, Yuting Song, Lixue Zhou, Yanhong Xu, Yunping Zhou, Effect of health coaching on blood pressure control and behavioral modification among patients with hypertension: A systematic review and meta-analysis of randomized controlled trials, International Journal of Nursing Studies, Volume 138, 2023, 104406, ISSN 0020-7489, https://doi.org/10.1016/j.ijnurstu.2022.104406.
