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GPs to take same-day referrals of patients with ‘irregular pulse’ from pharmacies

GPs to take same-day referrals of patients with ‘irregular pulse’ from pharmacies

Community pharmacies are to ‘urgently’ refer patients with an irregular pulse for a GP appointment on the same day, under a new hypertension case-finding scheme launched by NHS England.

The community pharmacy hypertension case-finding scheme aims to identify eligible patients with high blood pressure and to ‘refer them to general practice to confirm diagnosis and for appropriate management’.

Pharmacies should also urgently refer patients with ‘very high’ blood pressure or low blood pressure with regular experience of fainting or falls or the feeling they might faint, according to the service specification, published last month.

Patients with less urgent hypertension should be booked in to their GP practice within three weeks, NHS England said.

What the service specification says

‘All test results must be sent to patients’ registered general practices’, with those that do not require an ‘urgent’ referral sent by NHSmail or an ‘other secure digital process’ as part of a weekly summary.

For patients who require ‘urgent referrals’, pharmacies must phone the practice and share the results ‘immediately’ via the same avenues.

Patients with ‘very high clinic blood pressure’ – defined as 180/120mmHg or higher – or those with blood pressure ‘lower than 90/60mmHg that experience regular fainting or falls or feel like they may faint on a daily/near-daily basis should be booked for a same-day GP appointment.

Any ambulatory blood pressure monitoring (ABPM) that indicates ‘stage 2 hypertension’ – defined as average blood pressure of 150/95mmHg or higher – should also be booked for a same-day appointment.

Those with blood pressure below 90/60mmHg that experience dizziness, nausea or fatigue will receive ‘advice promoting healthy behaviours and be advised to see their GP within three weeks’.

Those whose ABPM confirms high blood pressure with an average of 135/85mmHg or higher but lower than 150/95mmHg will be referred to see their GP within three weeks Patients should be given a record of their test results.

Doncaster LMC chief executive Dean Eggitt said he has ‘several concerns’ about the service specifications, which he said are ‘risk-averse’ but ‘rightly so’.

He told Pulse: ‘Clinically it’s the right thing to do – if someone has an irregular pulse, there’s a risk of atrial fibrillation and with atrial fibrillation there’s a risk of stroke, so it needs urgent treatments to thin the blood to reduce the chance of having a disabling or deadly stroke. 

‘The problem we’ve got at the moment of course is that we can’t guarantee access to any patient at an urgent rate at the moment, so quite how we’re going to be able to follow up on the promise of an urgent same-day appointment I don’t know.’

He added that this leaves GPs in a ‘really difficult moral position’ as they have a patient they know is ‘at risk of disabling stroke and death’ but can’t guarantee seeing them.

Dr Eggitt said: ‘If that is the case, the only thing that we can do if we can’t guarantee seeing them is send them to A&E – so those patients may indeed actually just be forwarded to A&E which is absolutely the wrong thing to do.’

He added that pharmacists should be enabled to manage patients rather than just ‘diagnose and signpost’ them to GPs.

He said: ‘What we probably need to do though is to start considering how to work the world of medicine without putting everything either through a GP or A&E.’

The specification said that those eligible for the service include:

  • Adults aged 40 or over who do not have a current hypertension diagnosis
  • Patients under the age of 40 who ‘request the service because they have a recognised family history of hypertension’ – ‘at the pharmacist’s discretion’ and ‘by exception’
  • Patients aged 30-39 who are ‘approached about or request the service’ – ‘at the pharmacist’s discretion’
  • Adults ‘specified by a general practice’ for either clinic or ambulatory blood pressure measurement, via a ‘locally agreed process’

Pharmacies should refer any patient identified as eligible but where the ‘smallest/largest cuff available does not fit and therefore an accurate blood pressure cannot be obtained’ to their GP, it added.

The advanced service specification was ‘informed’ by a hypertension case-finding pilot that took place across a group of PCNs, NHS England said.

It comes as NHS England recently encouraged community pharmacists to proactively approach GPs and PCNs to recruit patients for their new hypertension service.

All pharmacies in England have been able to offer targeted cardiovascular (CVD) screening to patients aged over 40 since October as part of the hypertension case-finding service.

Meanwhile, a new PCN service focussed on tackling CVD diagnosis and prevention also launched in October in a ‘reduced’ form.

This is backed by the PCN incentive scheme, which rewards PCNs on the ‘follow-up’ of patients with one-off high blood pressure readings to ‘confirm or exclude’ hypertension, as well as the resulting rate of hypertension diagnoses.

And PCNs will be asked to ‘improve the identification of those at risk of atrial fibrillation’ through ‘opportunistic pulse checks’ when checking blood pressure from April 2022.

Click to complete relevant cardiovascular CPD modules on Pulse learning. 


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Please note, only GPs are permitted to add comments to articles

Dr N 2 December, 2021 10:01 am

Verrucas must have the same level of urgency as Stage 2 hypertension in that case.

Reply moderated
Thomas Robinson 2 December, 2021 10:16 am

He said: ‘What we probably need to do though is to start considering how to work the world of medicine without putting everything either through a GP or A&E.’

In this case the speed of access to ECG, would seem more important than GP access.

Of course this has been the trend for many years

Out of hours has gone, thank goodness, as have huge numbers of daytime calls. Many emergencies such as heart attacks and strokes are passed to ambulance. Maternity involvement has virtually ceased particularly intrapartum. Eye problems can be passed to optometrists and counselling largely passed to counsellors.

In the future it seems bizarre that breast lump clinics are not open access, similarly rectal bleeding clinics.

GP training, which I suspect has gone down a blind alley, has focused on the verbal technicalities of the conversation. In clinical situations such as this it is difficult to see how it adds tangible value,Speed and accuracy of diagnosis, and treatment, surely is more important.

Certainly I think the patient, taxpayer,public should have the choice.

Reply moderated
Michael Mullineux 2 December, 2021 10:43 am

Hang on a minute – otherwise healthy individual under 65 with irregular pulse is entirely different to over 65 arteriopath with the same. Is the plan really that of urgent appointments for ALL with irregular pulses?

Reply moderated
Robert James Andrew Mackenzie Koefman 2 December, 2021 10:45 am

all of these people would have been walking round for months without any symptoms, urgent same day access is not realistic in this health climate someone needs to stop this knee jerk response to everything now. if the govenment want this then they need to fund it and set up a hub somewhere in every ICS to see these patients not by us yet again !

Turn out The Lights 2 December, 2021 11:02 am

We are not an emergency service.Need to get in the queue of those in the queue for the free buffet.

Reply moderated
Richard James 2 December, 2021 11:05 am

This is nonsense. We all learnt in 1st year at med school that if a statement contains “always” or “never” then it’s false!

Irregular pulse in well patient is not a same day problem. Maybe a “see within a week problem.”

Cardiovascularly unstable patients – symptomatic low BP or irregular pulse with symptoms *should* be sent to A&E/UTC because they’re experiencing a medical emergency.

By all means ask that pharmacies contact practices to discuss cases which *may* need seeing urgently but specifying blanket requirements that certain clinical findings require same day appointments is obviously the wrong thing to do.

Reply moderated
John Clements 2 December, 2021 11:18 am

We are not funded to be an emergency service. We are not even funded locally to provide ECGs. Therefore these should all go to A&E

Reply moderated
Patrufini Duffy 2 December, 2021 11:24 am

You can “take” the referral same day, but you will be seen in 2 weeks. Like any other cardiological issue. The world doesn’t stop for AF.
We’ve not even got past “same day UTI” and “same day panic attack” yet. Next it will be “irregular anger issues- see GP”.

Slobber Dog 2 December, 2021 12:32 pm

Just block a couple of appointments per session
‘For pharmacy use only’

Reply moderated
Chris GP 2 December, 2021 12:51 pm

If I have space i am more than happy to see – although the outcome will be – please book an (unfunded) ecg with the PNA. Of course that means someone else won’t have access to that appointment.
If I am full – and it really is an “emergency” – I guess they should go to the place that deals with emergencies – A&E?
If that feels “wrong” then maybe the reason for that brings us back to the other valid points that have been made here – that it might not actually be urgent……

Reply moderated
Richard Greenway 2 December, 2021 1:49 pm

When commissioning these new services from Pharmacy -NHSE needs to make sure that the provider can see the entire job through.

So to diagnose AF – Pharmacists need to be able to clinically examine (undress) patients, and do an ECG then prescribe an anticoagulant where CHADS score suggests at the right dose that doesn’t interact with their current meds.

If GP is required along part or all of that pathway, this needs to be commissioned at cost as well and agreed locally. No point in having people dabbling.

Reply moderated
Decorum Est 2 December, 2021 3:14 pm

‘GP training, which I suspect has gone down a blind alley, has focused on the verbal technicalities of the conversation.’

Have a box of chocolates!!!

Bonglim Bong 2 December, 2021 8:44 pm

What happens on a Saturday?

Reply moderated
Jamal Hussain 4 December, 2021 1:51 am

It’s a sad state of affairs that patients who are having symptomatic hypotension and falling over on a daily basis are presenting to pharmacies and those who have verrucas are presenting to the GPs.
Patients really ought to triage themselves better. Or there should should be a national service that does that…
Oh there is.
It would be better if there was a national service that did it well. Maybe one day.

Reply moderated
Doc Getmeout 7 December, 2021 8:08 am

So this is deemed and labelled aa an emergency.

This is the NHS emergency department not a GP.

OR pharmacy to GP, GP to emergency dept.

Carpe Vinum 7 December, 2021 4:23 pm

Cue a long list of healthy folk with ectopics…..