Public health chiefs are calling on commissioners to crack down on GPs for QOF exception reporting of patients with high blood pressure, in plans to raise the proportion who are diagnosed with hypertension and treated with blood pressure controlling drugs.
In an ‘action plan’ launched today, Public Health England – in partnership with medical professional societies including the RCGP – has outlined a range of measures to improve diagnosis and treatment rates in England to levels reported in the US and Canada.
PHE says that despite improvements in drug therapy, only 37% of people with high blood pressure in England have it treated to reach the target level of 140/90 mmHg – compared with 53% in US and 66% in Canada – while there is ‘high variation’ between practices in achievement of the ‘even less stringent’ target of 150/90 mmHg that is rewarded through QOF.
It says high blood pressure, heart disease and stroke are all disproportionately high in patients from the most deprived backgrounds, and calls on CCGs to ‘minimise exception reporting for people with high blood pressure’.
It also wants CCGs to ensure better implementation of NICE-recommended stepwise antihypertensive therapy and lifestyle measures to reach the target of 140/90 mmHg – rather than the current QOF target of 150/90 mmHg – and is urging GPs to carry out audits of their patients’ blood pressure control and medications, while patients should be encouraged to take on self-monitoring.
The plan states that healthcare commissioners should ‘support spread of good practice in primary care of minimising exception reporting for people with high blood pressure, and optimising access to care of people from marginalised or disadvantaged groups’, and ‘support whole system action planning for the primary care system to implement NICE guidance particularly in terms of step-wise treatment increasing the number of agents and lifestyle changes to reach control with regular review of hypertensive patients’.
GPs have been accused of exception reporting inappropriately, in order to manipulate QOF scores and avoid more difficult to achieve targets, although a study revealed that any increase in exception reporting purely for financial gain was negligible.
Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee said he welcomed the focus on stepping up treatments and more use of self-monitoring in the report, but questioned the emphasis on the QOF blood pressure threshold and moves to limit exception reporting.
Dr Green said: ‘I was pleased to see the value placed on treatment with combinations of drugs, and also on home monitoring, which over recent years has revolutionised the way I manage hypertensive patients, largely by preventing dangerous over-diagnosis and treatment.
He added: ‘There do appear to be some misconceptions about QOF, in particular it is quite proper to have a difference between an audit and clinical target, especially where a very variable biological measurement is concerned, as it prevents overtreatment and preserves patient trust. If patients are to have personalised care provided in collaboration with their GPs, based on what is best for the individual and not simply target driven, then exception reporting is vital and indeed without it QOF would become unethical. This is particularly important for patients with comorbidities who form such a large part of the hypertensive population.’
Other recommendations are for GPs to carry out case-finding audits to the boost the detection rate in England – which it says currently lags 10% behind the US and 15% behind Canada – and to ‘ensure adequate provision of ambulatory blood pressure monitoring’ in order to make timely diagnoses.
Meanwhile local commissioners are urged to consider using enhanced pharmacy services to carry out opportunistic screening and support blood pressure management.
PHE estimates the NHS and social services could save £120 million over a 10-year period, if 15% more people had their high blood pressure diagnosed, while the same amount again could be saved if 15% more of those on treatment had their blood pressure controlled to 140/90 mmHg or below.