The West of England AHSN has been supporting the region’s Integrated Care Systems (ICS) and a number of Primary Care Networks (PCNs) to adopt a new framework for optimising blood pressure. The framework seeks to improve patient safety by effectively managing high blood pressure and reducing heart attacks, strokes and cases of vascular dementia.

This regional effort forms part of the national AHSN Network’s blood pressure optimisation programme, ending in March 2023, which implements a care framework for high blood pressure (known as hypertension) developed by UCL Partners. The framework aims to optimise clinical care and self-management to reduce hypertension and better manage those patients at risk of broader cardiovascular disease (CVD).

Health inequalities have also been challenged by ensuring sustained focus on, and engagement with, Core20 communities*, as well as those patients less likely to access traditional healthcare settings and services and who may be at greater risk of hypertension and/or CVD.

Why focus on blood pressure?

The NHS Long Term Plan states that the biggest area where the NHS can save lives over the next 10 years is in reducing the incidence of CVD. CVD causes a quarter of all deaths in the UK and is the largest cause of premature death in deprived areas.

The Global Burden of Disease Study identified hypertension and high cholesterol as leading risk factors that cause death and ill health from CVD. Effective treatment of hypertension and high cholesterol therefore substantially lowers the risk of death or severe ill health from CVD. Despite this, both are underdiagnosed and undertreated with around 30% of people with hypertension unaware of their condition, although this figure varies across England.

Work in focus

Bristol Inner City (BIC) PCN

Following analysis of local population health data a cohort of patients with high or uncertain blood pressure readings, or uncontrolled hypertension were identified.  A cluster of cases were located in a specific area of BIC PCN, which is one of Bristol, North Somerset and South Gloucestershire (BNSSG) ICS’s Core20 PLUS priority PCNs, with people from Black Caribbean or Black mixed backgrounds more likely to be affected.

This led to formation of a multi-disciplinary group of representatives from BIC PCN, BNSSG ICS, West of England AHSN and representatives from community health and care organisations working with the local community to improve blood pressure management.

148 patients with hypertension risk category 1 were identified by BIC PCN. In a pilot intervention at one practice, identified patients were invited to attend a drop in event with patients having their blood pressure checked, and if required, a GP consultation. Patients also attended a focus group to discuss lived experience of hypertension management.

At these focus groups, as well as at local Caribbean community groups, key solutions for improving hypertension management were suggested including an in-person community event. This event is scheduled for 8 March 2023 and local community groups, as well as patients from high-risk hypertension categories, have been invited. The suggestions made will continue to inform the approach taken by the PCN and ICS.

Gloucester Health Access Centre (GHAC)

The GHAC operates in the most deprived area of Gloucestershire ICS in inner city Gloucester. The PCN’s lead Pharmacist has been working with the AHSN to assess how the programme and care framework could complement existing work to improve overall blood pressure management and case finding for the practice and PCN.

With searches available from the care framework downloaded into the clinical system, the focus has been on identifying patients with very high blood pressure. In addition to a regular monthly search, a warning message now displays when a relevant patient record is accessed to encourage interventions. Improvements have also included drawing up a new blood pressure protocol for all practice staff to use, increased use of blood pressure monitors and regular review of reports to identify target patients.

Use of the framework has resulted in an additional 67 patients being included on the hypertension register. An additional 199 patients, with a previous raised blood pressure reading, have had a hypertension diagnosis excluded through the improved use of home blood pressure monitoring.

Future work will focus on supporting, through an outreach programme, the circa 40% of GHAC patients that do not have English as a first language and ensuring communication and approach suits their needs. This work will involve the practice team, PCN leadership, community organisations, local shops and places of worship with the aim of supporting patients, and registering those residents without a GP at GHAC.

Our approach

The West of England AHSN has provided project management support and met regularly with practice and PCN teams to review progress, challenges and lessons learned.  Webinars, and motivational coaching training to support effective patient communications, have been delivered, with more sessions planned during March 2023. Explore our events to hear more.

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

“It’s really positive to see the spread of blood pressure optimisation programme across the region and have the opportunity to work with clinicians that are passionate about reducing health inequalities, and improving risk, from hypertension and CVD.  Their enthusiasm has driven the project in each ICS and PCN, enabling them to develop an approach and community engagement that works for them and their patients.”

Dr Elizabeth Emsley, Bristol Inner City PCN Engagement and Co-production lead said:

“Prioritising a co-production approach has provided valuable learning for local health services in how we support patients. This learning extends beyond blood pressure management to health care in general and has allowed us to maintain a community focus.”

Richard Lee, lead Pharmacist for Gloucester Inner City PCN said:

“The collaboration between GHAC and the AHSN has ensured a continued focus on identifying and managing blood pressure for this challenging patient group. Each meeting has raised new ideas and challenges which have led to new ways of working and developing plans for new and sustainable projects.”

You can read more about our blood pressure optimisation programme here.  If you would like to discuss our work, please contact Senior Project Manager, Noshin Menzies.

* Core20PLUS5 is a national NHS England approach to inform action to reduce healthcare inequalities at both national and system level. The approach defines a target population – the ‘Core20PLUS’ – and identifies ‘5’ focus clinical areas requiring accelerated improvement.

Posted on February 21, 2023

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