Dear Sirs,
Hypertension case-finding is a priority for the National Health Service (NHS) in England.1 Opportunistic testing of patients at community pharmacies, dentists and opticians is being implemented. These interventions may lack digital integration with primary care and fail to proactively reach those who do not routinely use healthcare or who are at greatest risk of cardiovascular disease. In 2023/24, a place-based partnership (population 334,000) received funding to implement a scalable case-finding intervention focused on addressing health inequality. A population health management (PHM) approach was adopted, leveraging patient data to facilitate a remotely delivered clinical intervention.2
Out of 39 general practices, 20 participated (51%). Concern about increased workload was common, but most were ultimately satisfied, largely because GPs were only involved in managing abnormal results.
Using National Institute for Health and Care Excellence (NICE) guidance, patients were selected using blood pressure (BP) readings routinely recorded in electronic health records.3 Eligible patients had no prior diagnosis of hypertension, were not pregnant or nearing the end of life, and had a most recent clinic BP ≥160/100 mmHg or an average home BP ≥155/95 mmHg (stage 2 hypertension). The eligibility thresholds were lowered to 140/90 and 135/85 mmHg, respectively (stage 1 hypertension), for patients living in the 20% most socio-economically deprived areas nationally (index of multiple deprivation [IMD] quintile 1).
A GP-owned primary care network healthcare provider delivered the intervention. Patients were contacted by administrators and invited to complete a seven-day home BP diary. Four-hundred BP machines were purchased and delivered to GPs for loan to patients. Diaries returned to GPs were scanned into their electronic health record and remotely reviewed by a clinical pharmacist. Patients with abnormal BPs were subsequently reviewed by GPs and received usual care.
Over nine months, the provider attempted to contact 3,425 patients (51% female, mean age 60 years, 27% IMD quintile 1). Of these, 1,463 (43%) patients returned diaries, and 980 (29%) patients had results in the hypertensive range. One year after the intervention, 743 (22%) had been assigned hypertension diagnosis codes, and 431 (13%) were prescribed an antihypertensive drug. The proportion of patients in IMD quintile 1 was sustained in both diagnosis (27%) and treatment (28%) groups.
A review of NHS community pharmacy ambulatory blood pressure monitoring (ABPM) reported only 21% (271,887/1,326,446) of patients with a raised screening BP took up the offer.4 Published evaluation of clinical outcomes is lacking. The cost of the PHM intervention was £42 per diary returned, or £63 per hypertensive diary including start-up costs. The contracted cost of a community pharmacy ABPM consultation in 2023/24 was £45.
This novel intervention delivered equitable and scalable hypertension case-finding without diverting clinical resource. It was acceptable to patients and practices, effective and economically favourable.
Stephen Wormall
GP, Clinical Lead for Health Inequalities
Nottingham and Nottinghamshire Integrated Care Board
([email protected])
Conflicts of interest
None declared.
Funding
None.
References
1. Alderwick H, Dixon J. The NHS long term plan. BMJ 2019;364:l84. https://doi.org/10.1136/bmj.l84
2. Wormall S, Richardson K. Proactive total diet replacement referral for type 2 diabetes: a service evaluation. Prim Care Diabetes 2024;18:669–75. https://doi.org/10.1016/j.pcd.2024.10.004
3. 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
4. Tsuyuki R, Osasu Y, Liu S, Tong J. Uptake and results of the National Health Service England community pharmacy hypertension case-finding service. J Hypertens 2025;43(suppl 1):e29. https://doi.org/10.1097/01.hjh.0001115488.81580.56
