Over eight million UK citizens are at unnecessary risk of the avoidable consequences of hypertension because of inadequate blood pressure (BP) control.1 Improving this is a key objective of the Department of Health and Social Care, and is one of the five major priorities in the NHSE Core20PLUS5 approach to reducing healthcare inequalities.2 The national emphasis on hypertension case finding and management requires a significant increase in the availability of specialist advice and management, which can improve control and outcomes.
Approximately 5% of hypertensives may have a potentially remediable underlying cause, and up to 10% have hypertension resistant to usual therapies.3 The National Institute for Health and Care Excellence (NICE) recommends that these groups, as well as hypertensives under the age of 40 years, are referred to a specialist.4 This number will increase with the realisation that women who develop hypertension in pregnancy are at later significant increased risk of coronary heart disease, stroke and vascular dementia and need specialist follow-up and care.5 A British and Irish Hypertension Society (BIHS) survey estimated that each currently recognised hypertension specialist would have to see 20,000 patients each to satisfy these NICE recommendations.6
In this issue, Jamie Brady, his renowned and recently lamented father, Adrian, and others have surveyed primary care and found that two-thirds of all hypertension referrals were made to cardiologists, 92% for resistant hypertension, 60% in adults under age 40 years, and 34% because of medication side effects. Despite this, they found that 87.6% of cardiology trainees have had no specialist hypertension training.
The article comments that while the BIHS sets many UK standards for hypertension, it does little teaching for GPs and none for cardiologists in training. They suggest that the BIHS and British Cardiovascular Society (BCS) work with the Joint Royal Colleges of Physicians Training Board (JRCPTB) to include hypertension as a defined core part of specialist training in cardiology and that cardiology specialist trainees attend five to six hypertension clinics within their training district, over the four years of specialist training.
The 2022 JRCPTB Cardiology Training Curriculum7 mentions the word ‘hypertension’ 10 times, nine referring to pulmonary hypertension, and only once referring to systemic hypertension, and then hidden as a condition which ‘may underly coronary artery disease’!
The authors and readers may be unaware that a core group within the BIHS have previously met the BCS Executive to discuss this. The BCS expressed its inability to extend training or increase training numbers to facilitate this, citing the General Medical Council (GMC) as the limiting factor. Separate approaches have also been made by the BIHS on more than one occasion to the Royal College of Physicians (RCP) and to the Chief Medical Officers (CMO) of the four devolved nations, with unenthusiastic responses.
A curriculum for hypertension training developed by the BIHS,8 as a further training module (as exists within the clinical pharmacology curriculum), has already been shown to the RCP, but negotiations have been slow and lacked any clear willingness to progress.
The BIHS has provided hypertension training for some GP areas, such as the Isle of Wight, and this has been received with enthusiasm, but elsewhere primary care appears to have other priorities than to learn about better hypertension care, as long as the quality and outcomes framework (QOF) is satisfied, possibly assuming that they know enough for what they believe is a GP issue.
A 10/5 mmHg reduction in BP over a five-year period can reduce heart failure by 46%, stroke by 37%, coronary disease by 22% and cardiovascular death by 20%.9–11 It seems a poor choice to prioritise cardiology training on acute cardiology intervention, imaging, arrhythmia, heart failure, and inherited conditions without having achieved a more than passing acquaintance with the complexities of hypertension assessment, investigation, and management.
The BIHS is more than willing to extend its training offers beyond its webinars, annual scientific meeting, website training materials, and local lectures, but take-up by primary care and others has been poor.
It is timely that Brady et al. have highlighted the unmet need for proper training in hypertension. To achieve this, each of the key organisations – the Royal Colleges, Societies, Integrated Care Boards, and patient advocacy groups like Blood Pressure UK – must collaborate with the Department of Health, which has established disease prevention as its primary mandate.
Conflicts of interest
None declared.
Funding
None.
Editors’ note
See also the article by Brady et al. at https://doi.org/10.5837/bjc.2026.027.
References
1. British & Irish Hypertension Society (BIHS). British & Irish Hypertension Society (BIHS) response to the WHO Global Report on Hypertension 2025. September 2025. Available at: https://bihs.org.uk/news/24/british_irish_hypertension_society_bihs_response_to_the_who_global_report_on_hypertension_2025/
2. NHS England. Core20PLUS5 (adults) – an approach to reducing healthcare inequalities. Available at: https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/
3. Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and how to screen? Eur Heart J 2014;35:1245–54. https://doi.org/10.1093/eurheartj/eht534
4. National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. NG136. London: NICE, 2019. Available from: https://www.nice.org.uk/guidance/ng136
5. Poon LC, Nguyen-Hoang L, Smith GN et al. Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO best practice advice. Int J Gynecol Obstet 2023;160(suppl 1):22–34. https://doi.org/10.1002/ijgo.14540
6. Lewis PS. Specialist treatment of hypertension – who should do this? How should they be trained? Presentation on behalf of British & Irish Hypertension Society at the British Cardiovascular Society Annual Conference, Manchester, UK, 5–7 June 2023.
7. Joint Royal Colleges of Physicians Training Board. Curriculum for cardiology training. Implementation August 2022. London: JRCPTB, 2022. Available from: https://www.thefederation.uk/sites/default/files/Cardiology%25202022%2520curriculum%2520FINAL%2520July%25202022.pdf
8. British and Irish Hypertension Society. BIHS hypertension specialist accreditation scheme. Available at: https://bihs.org.uk/education/accreditation.aspx
9. Sobieraj P, Nilsson PM, Kahan T. Heart failure events in a clinical trial on arterial hypertension: new insights into the SPRINT trial. Hypertension 2021;78:1241–7. https://doi.org/10.1161/HYPERTENSIONAHA.121.17360
10. Wang Z, Richart T, Jin Y, Staessen JA, Liu L. Blood pressure lowering for the prevention of stroke recurrence. Eur Cardiol 2010;6:37–40. https://doi.org/10.15420/ecr.2010.6.1.37
11. Ettehad D, Emdin C, Kiran A et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2015;387:957–67. https://doi.org/10.1016/S0140-6736(15)01225-8
