Hypertension case-finding service
Hypertension case-finding service
This page contains information about the Hypertension case-finding service which will be commissioned as an Advanced service from 1st October 2021.
Work is still underway to finalise the service specification and other details; additional information, guidance and support materials will be made available to contractors as soon as possible.
Page last updated on 6th September 2021.
Click on a heading below for more information
The 5-year Community Pharmacy Contractual Framework (CPCF) agreement reached in July 2019 included a plan to pilot case finding for undiagnosed cardiovascular disease.
In 2020, NHS England and NHS Improvement (NHSE&I) commenced a pilot involving pharmacies offering blood pressure checks to people 40 years and over. In some pharmacies within the pilot, where the patient’s initial blood pressure reading was elevated, they would be offered 24 hour ambulatory blood pressure monitoring (ABPM), which is the gold-standard for diagnosis of hypertension.
Following the initial findings of the pilot, the Department of Health and Social Care (DHSC) and NHSE&I proposed the commissioning of a new Hypertension case-finding service, as an Advanced service, in the Year 3 negotiations.
The policy background
Cardiovascular disease (CVD) is one of the leading causes of premature death in England, affecting seven million people and accounting for 1.6 million disability adjusted life years.
This places a financial burden on the NHS of approximately £9 billion per year.
Hypertension is the biggest risk factor for CVD and is one of the top five risk factors for all premature death and disability in England. An estimated 5.5 million people have undiagnosed hypertension across the country.
CVD is a key driver of health inequalities, accounting for around 25% of the life expectancy gap (27% in men and 24% in women) between rich and poor populations in England. Those in the most deprived 10% of the population are almost twice as likely to die as a result of CVD than those in the least deprived 10% of the population. Additionally, 60% of excess mortality for those living with severe mental illness can be attributed to preventable physical health conditions, such as heart disease.
Residents of the most deprived areas in England are 30% more likely to have high blood pressure (BP) compared to those in the least deprived areas . Community pharmacy BP monitoring has the potential to increase the detection of hypertension within local populations and is expected to positively impact health inequalities by targeting people who do not routinely see their GP or use other NHS services.
The NHS Long Term Plan commits the NHS to reducing morbidity and mortality due to CVD, tackling inequalities and a shift towards prevention strategies. It specifically states that community pharmacy, in collaboration with other providers, will provide opportunities for the public to check on their health through tests for high BP and other high-risk conditions.
In February 2019, as part of the Cardiovascular Disease Prevention System Leadership Forum, NHSE&I published new national ambitions for the detection and management of the high-risk conditions. The ambition for hypertension is that 80% of the expected number of people with high BP are detected by 2029, and that 80% of the population diagnosed with hypertension are treated to target. At the time of publication of the NHS Long Term Plan, NHSE&I and Public Health England (PHE) estimated less than 60% of people with hypertension had been diagnosed.
Working with Primary Care Networks
Introduction of the Advanced service will support the work that general practices and wider Primary Care Network (PCN) teams will be undertaking on CVD prevention and management, under changes to the PCN Directed Enhanced Service which will commence on 1st October 2021.
From that date, PCNs must improve diagnosis of patients with hypertension, in line with NICE guideline NG136, by ensuring appropriate follow-up activity is undertaken to confirm or exclude a hypertension diagnosis where a blood pressure of ≥140/90mmHg in a GP practice, or ≥135/85 in a community setting, is recorded.
As part of this, PCNs must work pro-actively with community pharmacies to improve access to blood pressure checks, via the hypertension case finding service.
In 2022/23, PCNs must ensure processes are in place to support the exchange of information with community pharmacies, including a process for accepting and documenting referrals between pharmacies and GP practices, in relation to the hypertension case finding service.
The service will have two stages – the first is identifying people at risk of hypertension and offering them blood pressure measurement (a ‘clinic check’).
The second stage, where clinically indicated, is offering 24 hour ambulatory blood pressure monitoring (ABPM). The blood pressure test results will then be shared with the patient’s GP to inform a potential diagnosis of hypertension.
Contractors opting to provide the service must undertake both stages of it, where clinically required, i.e. it is not possible to just undertake clinic BP readings and not ABPM.
To start with, the service will only be provided by pharmacists, however if changes to the VAT rules can be agreed between DHSC, HM Revenue and Customs and HM Treasury, to ensure pharmaceutical services provided by other staff, but under pharmacist supervision are VAT exempt, the service will be modified to allow better use of skill mix.
PSNC is working with DHSC and NHSE&I to finalise the service specification, which will be published as soon as possible.
In the meantime, contractors wanting to gain a more general understanding about the service can read the additional information below and review the documentation used in the NHSE&I pilot:
The pilots did not involve all pharmacies providing ABPM and there will be other differences between the pilot process and the eventual Advanced service specification, but the broad approach to the service will be similar.
BP meters to be used in the service
As part of preparations to provide the service, contractors will need to purchase or rent equipment for each of the two stages of the service – Clinic blood pressure check and 24-hour ABPM – unless they already have equipment which meets the required standards.
Equipment that is to be used in the service must be validated by the British and Irish Hypertension Society (BIHS) (as recommended by NICE), so contractors must use a ‘normal’ BP meter and an ABPM which are included on one of the two following BIHS lists:
Points to note:
- ABPMs must be reset for each service user;
- To meet the service specification requirements, validation, maintenance and recalibration of both clinic blood pressure monitors and ABPM devices should be carried out periodically according to manufacturers’ instructions; and
- Infection control measures and cleaning must be carried out as per the instructions of the manufacturer or supplier and in line with current infection control guidance.
Considerations before purchasing/renting equipment
Contractors may find it useful to refer to the Medicines and Healthcare products Regulatory Agency guidance on the purchase, management and use of blood pressure measurement devices when selecting equipment for this service.
Before a decision is made about the purchase or rental of equipment, there are several considerations contractors may need to think through to ensure they have weighed up the additional requirements, implications and costs associated with provision of the service when using their selected equipment.
A non-exhaustive list of some of the considerations can be found below:
- Is maintenance and training included in the purchase price?
- If equipment is broken, does the supplier provide a spare whilst it is being repaired?
- Calibration versus replacement cost and the carbon footprint of both activities;
- Frequency/cost of cuff replacement and other consumables;
- Complexity of use – time taken to use (and explain use, in the case of ABPM);
- For clinic meters, do they automatically take 3 measurements and flag irregular pulse (this feature is very beneficial, but optional)?
- For ABPM, the usability of any inclusive software to support set up for the patient and interpretation of readings. Additionally, software and hardware compatibility with existing pharmacy IT systems needs to be considered, e.g. can you plug the meter into a USB port on a PC in the pharmacy; and
- Insurance to cover accidental damage to either type of meter and to cover the theft or failure of a patient to return ABPM.
To provide the service, pharmacists must:
- Be familiar with the NICE guideline Hypertension in adults: diagnosis and management [NG136];
- Have read and understood the operational processes to provide the service as described in the service specification (when this is published); and
- Have completed the recommended training on how to use the blood pressure monitoring equipment which should be provided by the equipment manufacturer/supplier.
Additional optional training
Pharmacists wanting to undertake further training on hypertension, understanding vascular risk and behaviour change interventions can do so on an optional basis to support their own continuing professional development (CPD).
Support with additional CPD can be found on the CPPE hypertension gateway page of the CPPE website.
The following fees have been agreed for the service:
- A set-up fee of £440;
- A fee for each clinic check of £15; and
- A fee for each ambulatory monitoring of £45.
In addition, the following incentive fees across Years 3, 4 and 5 of the CPCF 5-year agreement, will be available. Pharmacies must reach a threshold of ABPM activity to trigger the payment of the incentive fee.
- An incentive fee of £1,000 will be available if 5 ABPM intervention are provided in 2021/22;
- Followed by a payment of £400 in the subsequent years if the pharmacy reaches the thresholds for those years (15 ABPM interventions will be required in 2022/23 and 20 in 2023/24).
Contractors who sign up after Year 3 must achieve the ABPM activity thresholds specified for the given financial year and will receive £1,000 as a first payment. If a contractor signs up in Year 3 and fails to do 5 ABPMs, they can earn £1000 by doing 15 ABPMs in Year 4. These incentive payments will be funded separately (i.e. from outside the pharmacy global sum) by NHSE&I to incentivise case finding in line with the ambition outlined in the NHS Long Term Plan.
To achieve these targets, contractors will need to first identify people in whom ABPM is indicated, i.e. people with high clinic blood pressure measurements who then accept ABPM with accompanying support and advice.
The incentive fees will help contractors to fund the capital cost of purchasing a suitable clinic BP meter and an ABPM.
If changes to the VAT rules can be agreed between DHSC, HM Revenue and Customs and HM Treasury, to ensure pharmaceutical services provided by non-pharmacists, but under pharmacist supervision are VAT exempt, the service will be modified to allow aspects to be provided by the wider pharmacy team and the fees will be amended to reflect the greater use of skill mix within the service.