Richard Lee, Lead Pharmacist with Gloucester’s Inner City Primary Care Network (PCN) explains why he is hopeful a project that targets people with high blood pressure to reduce their risk of heart attacks and stroke could be used as a blueprint for tackling other health conditions.

Prevention is better than cure

One Gloucestershire Integrated Care System is looking at new ways of diagnosing and managing high blood pressure, or hypertension, with support from the West of England Academic Health Science Network (AHSN).

The Blood Pressure Optimisation (BPO) Programme aims to prevent heart attacks, strokes and other forms of cardiovascular disease (CVD), working in partnership with primary care.

High blood pressure rarely has noticeable symptoms so people don’t realise they have it and it can go untreated. It then increases the risk of serious health problems like heart attacks and strokes. Although it’s a leading risk factor for CVD, it’s both preventable and treatable.

According to the UK Health Security Agency, CVD is one of the conditions most strongly associated with health inequalities – the term which describes unfair or avoidable differences in health across the population.

The central plank of the BPO is to improve the management of high blood pressure.

Richard said:

“The project supports us in case finding, in other words focusing in on people who are undiagnosed.

“Once someone is identified as having hypertension on the register they are seen by a clinician and there’s a plan in place to manage them.

“The project uses a ‘proactive care framework’ for hypertension which helps us tailor our approach to suit our population so that people’s cardiovascular health can be improved.

“This programme started as part of Covid Recovery, there was an acknowledgment that the number of people on the hypertension register had dropped due to a number of different factors.”

The programme in action

Risk stratification enables PCNs to run an automated search on their software system which produces a list of patients across four groups, according to priority.

Some won’t need to see a clinician urgently if they have normal blood pressure, others will need more urgent review if their blood pressure reading is higher and they have other medical conditions/diseases (comorbidities). If a patient has had no blood pressure check in 18 months they will be contacted by a healthcare assistant (HCA) to arrange an up to date reading and those with blood pressure above 140/90 will be invited for a review appointment.

Further improvements have included a new blood pressure protocol for practice staff. The project has resulted in an additional 67 patients being added to the hypertension register and another 199 with a previous raised blood pressuring reading have had a hypertension diagnosis excluded by the use of home blood pressure monitoring.

Other features of the BPO include:
• Self-management, which includes remote monitoring
• Using the wider workforce to support patients with remote care and self-care

Identifying Challenges

Richard explains why his PCN is exactly the type of demographic the BPO is zeroing in on.

He said:

“If you look at our patients, 40% don’t have English as a first language. About 10% of the patients at the Gloucester Health Access Centre (GHAC) are Polish and we understand that if you don’t have English as a first language, it may be more difficult for you to access services, meaning you may experience an obstacle that someone else may not.

“Translation may be a barrier we have to work around as it can make consultation a bit more difficult.
“People can experience a number of challenges, including financial issues and housing, so looking after their health may compete with other things although we know they can often be strongly linked.”

Richard and colleagues have secured a supply of blood pressure meters which they can loan to patients at high risk. Out of the 20 meters, 18 are currently on loan, including one which is helping an asylum seeker based in temporary accommodation to take regular readings.

A series of readings is necessary to make proper assessments and plot out the appropriate course of treatment.

Future goals

An aspiration of the project for the Inner City PCN is to train the wider workforce to outreach to community groups so that they can spread information.

The West of England AHSN has provided project management support and regular meetings to review progress, challenges and lessons learned.

Webinars, and motivational coaching training have been delivered to support effective patient communications. Teams are also encouraged to innovate.

Noshin Menzies, Senior Project Manager at the West of England AHSN said:

“It’s really positive to see the spread of blood pressure optimisation and have the opportunity to work with clinicians who are passionate about reducing health inequalities, and improving risk, from hypertension and CVD.

“Their enthusiasm has driven the project enabling them to develop an approach and community engagement that works for them and their patients.

“Working with Richard and the local team has been an excellent example of how national programmes can be tailored to the needs of specific PCNs and their populations.

“The work at Gloucester Health Access Centre (GHAC) has made a real impact and we are excited to see how it continues to improve outcomes for local people”.

Building on the momentum

The programme has been running since July 2022 and Richard and team are keen to make further strides. He is hopeful that the project at GHAC will be used as an example of good practice.

He said:

“We want to roll this out to the other practices in the PCN so they can get more loan blood pressure meters and we also want one in the reception area so people can come to the practice and check it themselves.

“There are a wide range of health issues linked to health inequalities and our work won’t stop with hypertension.

“We are looking at innovative ways to approach areas such as diabetes and respiratory conditions for our patients.”

Dr Graham Mennie, Clinical Lead and Chair of the Circulatory Clinical Programme Group at NHS Gloucestershire said:

“Work focused on preventing, detecting and managing high blood pressure has been identified as a priority across the ICS.

“The excellent work undertaken at GHAC presents an opportunity to share the learning from this programme with other PCNs and with other partners.”