Managing hypertension in Dudley clinical commissioning group (CCG)
Practice-based pharmacists worked with GPs to identify and manage undertreated hypertensive patients and to identify undiagnosed patients.
Dudley Metropolitan Borough Council engaged with general practice and used practice-based pharmacists to:
- identify patients previously recorded as having a high blood pressure reading, with a view to diagnosing more hypertensive patients
- manage hypertension to NICE targets rather than to QOF targets and thereby improve life expectancy and outcomes for people with hypertension and related diseases
Over 2,000 patients were reviewed and 1,096 new patients were diagnosed with hypertension over two years.
11,000 patients with hypertension were identified whose blood pressure was not managed to 150/90mmHg (reducing blood pressure from 150/90mmHg to 140/90mmHg reduces the risk of coronary heart disease by 22% and of stroke by 41%). Treatment to 140/90mmHg was achieved by 90% of practices.
What was involved
Dudley is ranked 118 out of 326 in the Index of Multiple Deprivation (2015) with a population of 316,000 (ONS 2014 mid-year estimates). The life expectancy gap at birth between the least and most deprived local deciles in Dudley is 9.7 years for males and 6.1 years for females (2011 to 2013).
A pharmacist-led audit in Dudley identified several underlying issues including:
- difficulty identifying patients with hypertension
- practices only treating patients to the QOF target, not the evidence-base
- patients both being not recalled and not attending follow-up appointments after diagnosis
- patients perceiving hypertension as not important, probably because this is silent and not a visible condition
This audit was used to gain CCG support for a hypertension project to be carried out in Dudley CCG general practices.
Following GP engagement, practice-based pharmacists (PBPs) used the EMIS primary care clinical system and the result of NHS Health Checks to audit high-risk groups and identify, screen and diagnose patients with hypertension.
Hypertensive patients were then managed to the evidence-based NICE blood pressure targets for specific diseases such as diabetes, not just to the previous QOF target of 150/90mmHg.
After the first year of the project:
- 11,000 patients had been diagnosed with hypertension whose blood pressure was not managed to 150/90mmHg
- 27,800 patients were discovered who were missing from hypertension registers
- prevalence increased by 63% due to newly diagnosed hypertension
- treatment to 140/90mmHg was achieved by 90% of practices
- treatment to 150/90mmHg increased from 73 to 85% of practices
- 550 patients (2% of the register) declined hypertension monitoring, but they each received information about the condition
- a link was made between deprivation and higher levels of undiagnosed hypertension
What works well
Critical success factors included:
- the CCG using a local quality premium to support the work of PBPs, with each practice submitting an individual practice prescribing action plan that over 3 years, has focused on a different patient sub-group, including patients with peripheral vascular disease, heart failure, diabetes and renal conditions
- discussions at practice level on how to improve within local GP practice populations
- offering PBPs as a ‘free’ resource to GP practices to complete the audit, review patients and manage hypertensive patients through independent prescribing (the project was carried out within the existing practice-based pharmacist budget as part of their annual work plan)
- the involvement of the main stakeholders in each Dudley general practice, within the Dudley CCG, the local NHS Trust’s cardiologist medical service lead and the Dudley Metropolitan Borough Council Office of Public Health
The CCG is continuing to focus on treating to the NICE evidence-based target in line with disease guidelines and using NHS Health Checks and EMIS Search and Report system to case-finding high-risk patients such as those with peripheral arterial disease and chronic kidney disease.
Email Clair Huckerby, Pharmaceutical Adviser, Dudley Clinical Commissioning Group at firstname.lastname@example.org.