Dilemma: Ambulatory blood pressure monitoring

You understand that ambulatory blood pressure monitoring is now the gold standard. Do you refer everyone to the local hospital for the diagnosis of hypertension or do you invest in your own equipment? Where could you find the money for these things?

CCGs must ensure provision of monitoring

There is a need to ensure that people with high blood pressure are identified and appropriately diagnosed and treated to minimize the potential cardiovascular outcomes.

The NICE GC 127 clearly has set the diagnosis of hypertension out of the traditional setting of repeated blood pressure assessments in general practice with the use of ambulatory monitoring.

CCGs cannot overlook the need to deal with hypertension where the population outcomes can be substantial if dealt with appropriately.¹ Not only has to ensure provision of the ABP but has to seek assurance regarding the quality control of the device and the quality and governance of the service.

There are three options on how to provide these services for the practice at this stage:

- The practice could invest in their own equipment. This is a partnership expense with no clear funding stream to follow the time or investment the practice will have to make. There is a clear training need also in this strategy as the ABP is more complex than just reviewing blood pressure results as previously used.

- The CCG could decide to utilize the established contract with the local cardiology service providers. This would allow the providers to anticipate the increase in demand and adjust accordingly. Clear decisions would be required to the nature of the report and the associated tariff cost. If a local provider does not supply open access testing then this could attract an out patient tariff placing a burden on the CCG. There are other providers of cardiovascular testing than hospitals and a CCG could look to alternative providers within a wider open market to attempt to off set its costs.

- The nature of the ABP report is that it requires interpretation rather than just supplying of data. This leads to a third option with hospital based provision of equipment and data, working with colleagues in community care for the interpretation. In this way a new demand on the clinical pathway is addressed but no single point put under exceptional pressure

Dr Matthew Fay is a GP in Shipley in West Yorkshire and a medical advisor to Atrial Fibrillation Association.

Set up a GPSI service

ABPM is indeed the gold standard measurement these days for the diagnosis of hypertension. However, the diagnosis can also be made by repeated home BP readings as well, as described in the NICE guidelines. I also think that, with frequent raised office readings, lifestyle interventions should be suggested anyway.

There is good evidence that raised office readings are associated with increased cardiovascular events and, more recently with the development of dementia. Certainly before starting medication a definitive diagnosis should be made one way or another.

Once you have an ABPM device you will find yourself using it increasingly frequently and I would recommend easy access to one. The cost of the devices is falling, but they remain a significant outlay.

Many CCGs have agreed to fund such machines for each practice but this depends on your CCG priorities and affordability. Some practices have paid for their own.

The way we have done it in Central Manchester is to have them centrally based in a GPSI service. The cost of referral is £30, which is paid by the CCG for each ABPM reading. The advantage is that they are centrally based and fitted by assistant practitioners who are used to using them. The alternative of referral to hospital usually incurs a full ‘first appointment’ tariff, unless your CCG can negotiate a lower price.

In the future more and more diagnostic investigations will become available in general practice. We need to get used to it, and find a funding stream that supports implementation of these tools.

Deflecting unnecessary referrals from secondary care is a persuasive argument to make to commissioning groups, but often requires a local champion to make the case, know the right levels, and to have patience.’

Dr Ivan Benett is a GP a GPSI in cardiology and clinical director of NHS Central Manchester CCG.

Arrange discounts with practices working together

Ambulatory or home monitoring is the gold standard for the diagnosis of hypertension.

If I needed to start on a lifetime of treatment I would want to be sure that it was needed and that I actually had the condition that was being treated. We have had ambulatory monitoring in our practice for the past six or seven years and find it very helpful to differentiate those people who have white coat hypertension.

I also use it to demonstrate to patients the normal variability of blood pressure and the need for treatment in those with sustained hypertension. It is difficult to manage hypertension properly without this equipment in practice and think that every practice should have easy access to a device. We now have three.

The purchase price is now very much more affordable, and surely discounts can be arranged if practices work together? This should be part of the normal practice equipment just like an otoscope or spirometer, both not cheap either.

The on-going cost involves the fitting of the device and explaining to the patient how it works and what is expected of them and also removing the device and downloading the results the next day.

It is important that the practice team members are trained to do this and in our practice at present a practice nurse fits the device although it could be a health care assistant and a member of our admin team down load the results and ensure that they are sent to the doctor.

As a commissioner I would support the provision of the service in primary care both as a cost saving measure but also to be more convenient to the patient.

It should be unnecessary to have a trying journey to a hospital to have the device fitted and then back the next day to have it taken off when this can be done in primary care. We had one of our devices provided in this way.

It is of course important however to ensure that the devices are regularly calibrated and that clinicians are confident at reporting the results.

NICE guidelines do allow the use of home measurements using reasonably priced but properly calibrated devices for the diagnosis of hypertension.

I hope that the days have passed when we are treating ‘hypertension’ on the basis of 2 or 3 clinic readings alone.

Dr Kathryn Griffith is a GP and a GPSI in cardiology in Nottingham.