How to address undiagnosed hypertension and health inequalities

In Derby, a pilot to address hypertension among at-risk populations who are less likely to use NHS services was so successful that nearly 30% of the patients checked were found to have high or very high blood pressure reading. Steve Hulme, chief pharmacy officer at NHS Derby and Derbyshire integrated care board (ICB), explains more about the pilot. 

In Derby, it is estimated that 9,656 people are living with undiagnosed hypertension – almost 4% of the city, which the 2021 census showed as having a population of 261,400.

The city’s population includes around 16% of people with Asian heritage and 4% of people with Black heritage – groups that have a higher-than-average risk of high blood pressure. Yet Asian and Black ethnic groups are also known to engage less with local primary care NHS services than white populations. And, to make it worse, the inner-city areas of Derby are classed as among the most 20% deprived in England.

To address this problem, a project to tackle health inequalities and undiagnosed hypertension was commissioned by NHS Derby and Derbyshire ICB, under the medicines management team, across the Derby City Council area.

Aims

The aim was to increase the number of blood pressure checks among the over-40s in the populations at higher risk of cardiovascular disease, heart attack and stroke and those who are often underserved by local NHS services.

Any patients who were identified as having a high blood pressure reading were to be offered a range of support to reduce their risk, such as advice on diet and lifestyle or signposting to other services.

NHS England provided one-off funding of £155,690 specifically to test models to meet the goal of increasing the numbers of blood pressure checks conducted on people who had not been checked recently and who were at risk.

This funding was split between two methods for finding and checking the right patients.

Methods

One approach was via GP practices in Derby and £80,000 was allocated to this element.

GP practices used risk stratification tools and searches to identify patients over 40 years old who were at higher risk of cardiovascular disease, who were less likely to present at a healthcare setting, and who had not had a blood pressure reading for at least five years. These patients were invited to receive a check, either at the practice or at other locations such as mobile and drop-in clinics around the city. Outreach was supported by interpreters, healthy living coaches and nurses.  

The second method was community based. Volunteers from a wide range of community organisations were equipped with blood pressure monitors and trained in how to use them to take readings. They were also trained to offer lifestyle advice and signpost anyone with a high reading to a local community pharmacy to receive a further check. The pharmacist was then able to confirm the reading and offer further advice, signposting and referral.

Volunteers were supported by a communications campaign to encourage the target audience to get a blood pressure check. This campaign was informed by significant engagement with the local communities, which provided research and insight into the existing knowledge and motivations of the target audience.

The communications campaign, public engagement, training and equipment for volunteers were allocated £75,000 of funding.

Outcomes

The programme ran for five weeks in September and October 2023. In that time, a total of 4,133 people received a blood pressure check. Of those, 1,228 (30%) were identified as having either a high or very high reading.

The GP practices had a target of checking 2,400 patients in five weeks and significantly exceeded that – 3,224 patients received blood pressure checks.

Over the same time frame, the community volunteers gave 909 blood pressure checks (against a target of 400) and a quarter of them (224 individuals) were identified with a high or very high blood pressure reading and signposted to their local pharmacy for further checks. The volunteers have continued to give regular blood pressure checks at a range of events and organisations, and a further 257 blood pressure checks were recorded from November 2023 to April 2024.

This means that blood pressure checks in the community are now a normal occurrence for many people in the target group.

Benefits

One of the benefits of the project was building a strong relationship of trust between ICB teams and local community organisations in inner-city Derby, particularly those that supported populations at risk and less likely to present at healthcare settings. As well as South Asian and Black groups, this also benefited other groups, including Derby’s deaf population, which is the largest in one city outside London.

Both the ICB and voluntary organisations gained a deep insight into community understanding of the risks of high blood pressure and where and how they could get a blood pressure check. By commissioning local community organisations, the ICB was able to greatly exceed the target numbers of people in the relevant populations who received a check. This, in turn, meant that people whose blood pressure was high could receive lifestyle advice or appropriate signposting to community pharmacy.

Another benefit of the project was ascertaining that the search and risk stratification tools used by local GP practices were effective in reaching at-risk populations. Almost a third (31%) of the people checked by GP practices were found to have a high or very high reading. This high percentage indicates effective identification, invitation and clinic design by the GP practices.

If we assume that most people whose blood pressure was found to be high then took positive action – through diagnosis and medication if appropriate, or through lifestyle change – this programme will have prevented many heart attacks and strokes.

Challenges

There were challenges too, though.

Community sector partners were unfamiliar with NHS tools and techniques for project management, and this required compromise. Those in the community and the NHS had to adapt their approach and learn from each other. For example, NHS colleagues accepted that data returns on the numbers of people who received checks could not be provided to a strict timetable but, on the flip side, the community sector greatly exceeded the targets set for the number of checks carried out by being given the freedom to deliver the project in their way.

Another challenge was the time-limited nature of the funding. This made it difficult to work through processes for project design, funding approval, commissioning and implementation and meant we had to focus on the aspects we could deliver. We have learned positive lessons from the experience.

In particular, we would have collected data for how many of those checked went on to receive a diagnosis of hypertension and the subsequent prescription of medication. This would have allowed us to better quantify the impact of the project and, therefore, the number of heart attacks and strokes avoided.

It would also have been useful to collect data on the increase in visits to community pharmacy for blood pressure checks in the neighbourhoods we targeted, allowing us to make a direct link from our community engagement to the actions taken by local people.

Future

Around 55 volunteers are now trained and continue to take blood pressure readings in 17 community groups on a regular basis. Underspend from the project was used during February and March 2024 to run a further communications campaign to signpost people to community pharmacy to receive a free blood pressure check.

Partnership working between NHS and community organisations, informed by evidence and research, was a success and the ICB plans to use this model again for further interventions to tackle health inequalities.