We hope our latest edition of Health Matters – on the subject of “Combating high blood pressure” – will help you and other health professionals by compiling key facts, figures and evidence of effective interventions.
Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters high blood pressure questions we received from professionals across the UK at and after the launch teleconference.
We’d love to hear from you at firstname.lastname@example.org.
Question 1 (Engaging pharmacists in blood pressure testing)
How are we engaging with pharmacists to get them to offer blood pressure checking, as it’s such a fabulous opportunity? Is there something that is being rolled out that would encourage pharmacists right across the country, because in my area we don’t have that level of engagement with our pharmacies?
Community pharmacies are absolutely at the heart of the clinical response to this issue. They have a great opportunity, because they have such a footfall through the door and they are often much more accessible to individuals to have their blood pressure tested. Additionally community pharmacists are moving beyond the time when they just measured blood pressure and sent the patient off to the GP, perhaps concerned that the patient is in danger of having a stroke in the near future. Actually, a lot of pharmacists are now using their enhanced skills to take the blood pressure, to talk to the patient about lifestyle changes they might make, to arrange more than one reading to see if it is really high, and in some areas pharmacists are actually doing the diagnosis and the subsequent management of high blood pressure, working with the GP and the rest of the team.
In just a few weeks’ time, Pharmacy Voice is going to be launching a report on blood pressure, which is actually going to try and galvanise and bring commitment across the pharmacy community on what their role and contribution is in tackling high blood pressure. So hopefully that will resonate with your pharmacy colleagues and we’ll see across the country that greater commitment.
We would also like to draw your attention to the recent publication the NHS Right Care CVD Prevention Optimal Value Pathway, which was published just before Christmas. This is now rolling out across CCGs that have cardiovascular disease as a value priority, which is probably going to be around half of the CCGs. The Pathway includes the six higher risk conditions, including atrial fibrillation, blood pressure and cholesterol. Right Care Delivery Partners will be working with CCGs to help them identify the gaps in performance, the scope for improvement and doing things differently to support general practice. So CCGs working with Right Care will be urged to look at what they are doing to use their community pharmacies and how they can commission differently to use that potential. So that’s quite exciting, that’s just taking off now.
Question 2 (Improving high blood pressure diagnosis in CCGs)
How can the local Public Health team work with practices where the gap between prevalence and estimation is wider? Is there any plan from PHE to work with those practices systematically to increase the number of undiagnosed people?
A great source of advice on this is the Blood Pressure - How Can We Do Better pack. This was written by a group of GPs, nurses and pharmacists working with PHE, British Heart Foundation and others. There is one pack for every CCG with local data showing gaps in detection and treatment. There are key messages on how to improve detection and management at both practice and CCG level.
Question 3 (Testing blood pressure in the workplace)
My question is about increasing the opportunistic testing for high blood pressure. Many people are developing workplace interventions and we've done some very minimal testing of blood pressure. These tests seem to be very popular with staff but our problem was really deciding on how we measure it. Is there a dedicated best choice for equipment? Also, how are we doing the test these days - is it the best of three? Is it recommended that people with a recorded high blood pressure then go on to GPs for 24-hour testing? And is there a letter, a template on which we record the recordings or simply just advising the member of staff to visit their GP
In terms of what equipment to use the British and Irish Hypertension Society does publish a list of validated blood pressure testing machines that can and should be used. And if you're concerned about how to advise people when they have a blood pressure reading, perhaps helpful advice would be for them to take their reading to the NHS Choices website to enter in there on their blood pressure tool. It gives clear guidance that we've worked through on when they should visit the nurse or the doctor and what the level of urgency is and what that specific result means to them as individuals.
Testing blood pressure in the workplace is a really effective way to increase opportunistic testing. In fact, last year Public Health England put blood pressure machines around the workplace to allow colleagues to test themselves. We developed an online system to allow people to automatically load this information onto their computers and print out automated letters for their GP. We are having conversations with colleagues at the British Heart Foundation about how could we take some of the learning that we have – I'm sure there are many colleagues across the country that have been testing in other ways. We will be looking at putting together a practical guide or resource that would support people to be able to test blood pressure within the workplace.
Question 4 (Following up blood pressure testing in the workplace)
How we can trace people who have been opportunistically picked up and referred to the GP? The only time I could find out was by asking for feedback at the workplace where following BP checks that were followed up with the GP for further test, staff reported that they were diagnosed with high BP?
This would be difficult in individual cases, as GPs will not share confidential information about patients. If you want to track subsequent diagnosis it would need to be part of a local protocol agreed with the GPs and patients/clients and would require clinical coding to show that the individual had come through the workplace programme. But that is quite complex to set up and make work!
Question 5 (Which venues are best for opportunistically checking blood pressure)
With regard to opportunistic case finding for high BP in community settings, what is the evidence base for effectiveness of this as an intervention? And of the settings mentioned – workplace, community centres, gyms, supermarkets is there evidence of which ones are most effective? I ask this because we could of course attempt to use all of those settings however with limited resources and capacity to engage, it would be helpful to know which ones have proven to be most effective and why so that we can target our efforts effectively.
In terms of what is available to guide you on the most effective venues, unsurprisingly, there is not an abundance of published evidence. However, we have put together a number of helpful resources, guidelines and case studies, which you may want to explore. We are also working with the British Heart Foundation to bring together one central resource hub for colleagues working on CVD prevention, so we will be sure to update colleagues once this has been developed.
Finally, we would recommend that you also take a look at the independent report which we commissioned for the Blood Pressure System Board to consider actions agreed in our Tackling High Blood: evidence into action plan, which did review a number of studies and which you may find helpful.
Question 6 (Is blood pressure testing an opportunity to detect AF?)
Are you also promoting detection of atrial fibrillation (AF) when opportunistically measuring blood pressure? Are there machines that can detect both?
When we take blood pressure, it is clearly an opportunity to pick up many people with undiagnosed atrial fibrillation, because of the five-fold increased risk of stroke. It is now in the NICE guidance that if any health professional is measuring blood pressure, they should be taking the pulse before they measure the blood pressure to see if it’s irregular, and if it is, then to go on to get an ECG to see if it’s due to atrial fibrillation. There are blood pressure machines out there now that can detect atrial fibrillation, for instance the WatchBP Home A sphygmomanometer which has had a positive medical technology assessment from NICE. Many surgeries around the country now have a number of these monitors to use in people who have AF or in whom they find they have an irregular pulse.
The NHS Health Check programme protocol states that the pulse should be checked for irregularity before going on to measure the blood pressure. So we do expect the NHS Health Check to identify people with undiagnosed AF as well.
Question 7 (Return on Investment)
I’m leading a hypertension project across an STP area. Local commissioners have been keen to know what their local return on investment (ROI) will be, in addition to the kind of the national estimates of costs avoided that have already been done. I’m aware of a few tools - the ROI tool that’s on the Yorkshire Public Health Observatory site, and also some figures included in the menu of preventative intervention, I think based on the Dudley pharmacists. I'm interested really in whether there are plans to develop a more interactive ROI tool?
It would be very helpful to have more comprehensive ROI tools. However there is a strong case to be made to commissioners, because you can identify, in your CCG or across your STP, the number of people with poorly-controlled high blood pressure, and the number who are not controlled to target. We know from very robust evidence that for every 10 mmHg drop in blood pressure in your hypertensive population, you will reduce strokes and heart attacks and premature death by about 20%. These are really big numbers and even if you did only half or a quarter that well, that’s still a lot of strokes and heart attacks locally. So in the absence of final robust ROI evidence, that’s the answer to the commissioners. They can wait for the perfect evidence, or they can start taking action now for what is clearly a very big problem with a very big potential for return.
PHE has plans to develop a fuller ROI tool in the next financial year. There is more evidence coming out, particularly on certain types of interventions by both nurses and pharmacists. We can use that information in some of our tools. We aim to develop something a little bit more systematic.
Question 8 (Encouraging use of free physical activity resources)
As a parks charity operating across the UK, we’re very interested in encouraging more physical activity to meet our own public health objectives, as well as those of Public Health England. Using our free to enter sites, we have a number of health walks that our rangers already run, and a number of other activities such as green gyms and things like that. We find it difficult, as a charity provider, to access the local NHS providers or funders, and what is the best way for us to work with Public Health England, to meet your aims of increasing physical activity in the general population?
We have an NHS Health Check conference coming up in only a few weeks’ time that is going to be attended by 400 colleagues working across the country, from primary care and from local government. Your service is the ideal sort of thing that we should have in our marketplace. So if you want to make contact, we’d love for you to be there and for you to be able to have that conversation directly with commissioners, with providers that are working on this. We have strong networks across the country, so each PHE centre will have an NHS Health Check network where again you would be able to go along and talk to those commissioners. So do please reach out to us and we’d be very happy to help you.
Question 9 (Prevalence of high blood pressure)
The content states that for every ten people who are diagnosed with high blood pressure, a further seven remain undiagnosed. Yet with NHS Health Check it's one new case in 27 checks, which implies that almost everyone who has undiagnosed high blood pressure didn't receive a Health Check or are under 40, which I find difficult to give full credence to.
The two statistics you mention are both valid. Ten diagnosed versus seven undiagnosed is based on the fact that we have a model of hypertension created by our colleagues at Imperial College, which estimates the number of people with hypertension and those who remain undiagnosed.
But the second statistic – the Health Check analysis is around the actual diagnosed information. They are two different pieces of information saying different things, one based on a model, the other based on actual information, but both are true.
Question 10 (Risk factors cited on the Infographics)
I see slide 2 says that the first infographic states that high blood pressure is the 3rd biggest risk factor for premature death and disability in England after smoking and poor diet. I am curious as to why hypertension is viewed as a separate risk factor for premature death in itself when both smoking and diet contribute to hypertension themselves? Secondly, why isn’t smoking on the list of modifiable risk factors infographic?
You are right that dietary (particularly sodium) behaviour influences blood pressure risk, but The Global Burden of Disease 2015 (GBD) is explicit in stating that each risk attribution to diseases are not additive in their estimates. All GBD is saying is that raised blood pressure, as an independent risk, is attributed to a greater (or lesser) amount of disease compared to the independent effects of poor diet. Measuring the joint effects of several specific risk factors on disease outcomes is an extremely complex field and GBD has not yet attempted to undertake these methods for its estimates. There is no clear evidence for smoking having any independent long-term effect of raising blood pressure.
Question 11 (Importance of dietary salt as a risk factor for high blood pressure)
Is PHE’s focus on reducing dietary sugar reducing how much effort can be put behind further efforts to reduce dietary salt?
We will be discussing this issue at the next Blood Pressure System Leadership Board. In the meantime PHE’s Be Food Smart app includes information on salt swaps as well as on sugar. We have had millions of downloads of the app, which is allowing people to scan thousands and thousands of food products.
Question 12 (Genetics as a risk factor high blood pressure)
In Health Matters, under risk factors, it mentions that Research on twins suggest that up to 40% of variability in blood pressure may be explained by genetic factors, which I take is not the same as saying that it accounts for 40% of your risk. I’m just interested because there’s been a little bit of conversation back in 2010 and again quite recently I think, about the issue of variability in blood pressure and how much risk it accounts for.
There is clearly an important genetic component to lots of things in our lives, probably including our blood pressure, and our likelihood of developing blood pressure when faced with environmental and behavioural factors as well. There may also be a genetic variation in how we respond to different medications. So there are going to be genetic and other influences, but the central issue we’re focusing on here is that we have such an opportunity because there are so many people with undiagnosed high blood pressure and untreated high blood pressure who would actually respond to support for lifestyle change, environmental change, and medical treatment.
If you have any further questions, the team here at Public Health England will be very pleased to answer them. Please send your questions via email to email@example.com.
Do please keep on sharing your stories about how you have used the Health Matters materials to communicate your messages and to get things done, or if you have ideas for improvements. Just send an email to firstname.lastname@example.org.