Berkshire East: Nithya Nanda, GP Clinical Lead/Sangeeta Saran, Associate Director Planned Care and Slough Operations, NHS East Berkshire CCG
Frimley STP: Claire Norfolk, CVD Workstream Lead
Oxfordshire: Kiren Collinson, Clinical Chair, Oxfordshire CCG
Berkshire West: Heike Veldtman, Chair for LTC, Berkshire West CCG/Sarah Bow, Transformation Lead, Long Term Conditions
Buckinghamshire: Raj Thakkar, Clinical Lead for Thames Valley LTC/CVD programme, Clinical director for planned care in Buckinghamshire/Stuart Logan, Clinical Director for Long Term Conditions/Steve Goldsmith, Head of Long Term Conditions, Ill Health Prevention and Supported Self Care
The Berkshire East CCG Medicines Optimisation Team (MOT) developed a systematic audit to support practices in finding people who either had hypertension or were at risk of developing hypertension.
Over 12 months, the audit was delivered in all 48 practices in East Berkshire. MOT pharmacists then added people with hypertension to disease registers or referred people for diagnosis.
After 12 months, there was a 12% increase in the number of people diagnosed with hypertension, a significantly higher increase than in the previous two years and a bigger increase than any other CCG in England in 2015/16 and 2016/17.
The clinical pharmacist team within the North East Hampshire and Farnham CCG are:
• Embedding routine BP/pulse checks in all relevant clinics and amending all protocols in LTC clinics to include BP/AF checks.
• Conducting system searches within a hypertension clinic, making phone calls to check on home monitoring etc, as well as see people in person.
• Developing a healthcare assistant-led hypertension clinic for routine follow-up of patients with controlled hypertension, creating capacity for clinical pharmacists to manage poorly controlled/complex cases.
Slough CCG worked with multidisciplinary professionals (pharmacists, nurse specialists, GPs, Public Health and patient representatives) to mobilise the hypertension programme by:
• Developing a dashboard to support detailed analysis of hypertension within Slough CCG. This incentivised programme supported GP practices to increase the case finding and prevalence of hypertension by at least 5%.
• The public health campaign Cardiowellness was developed to raise awareness of high blood pressure and to encourage uptake of NHS health checks.
• Training for GPs had been rolled out across the CCG, focusing initially on the poorer performing practices.
Ringmead Medical Practice (Berkshire East) uses a collaborative approach to identify and treat patients with diagnosed and undiagnosed hypertension.
The practice promotes five steps to detect and treat hypertension:
1. Use every method to diagnose or monitor hypertension.
2. Check that the measurement is correct.
3. After diagnosis: explain complications, side effects of avoiding treatment and run regular reports to identify those who have uncontrolled hypertension.
4. Encourage positive lifestyle changes with advice at every contact.
5. Follow NICE/BHS guidance and review 1-3 monthly until controlled, then 6 monthly or annually
Oxfordshire CCG has been working with Oxfordshire County Council to identify practices who have:
• Lower responses to invitations to attend NHS Health Checks.
• Lower rates of follow up of patients identified at risk during NHS Health Checks, particularly in relation to hypertension and cholesterol.
Analysis of QOF data is carried out to identify practices who have low achievement and/or high levels of exceptions in the cardiovascular indicators.
Practices achieving good improvements are consulted to understand their approaches & the tools they use. This best practice is then shared with all practices, with an offer of a supportive visit to those who would benefit most.
The NHS Health Check service is now running in Buckinghamshire, systematically inviting all 40-74 year olds without known cardiovascular or related disease for assessment and estimation of ten-year risk of having a heart attack or stroke, followed by discussion and where appropriate, offer support around reducing their risk. By September 2012 nearly 46,000 people had been invited and over 18,000 received this Health Check.
Quality premium measure for 2018/19 for hypertension asks for an increase in the number of patients on the hypertension register by 1%. To improve hypertension detection rates, 109 Watch BP devices have been offered across Berkshire West for improving screening during LTC reviews.
Support for lifestyle changes is available to patients within Buckinghamshire practices who have already had a heart attack or stroke. QOF incentivises GP practices to optimise secondary preventive treatment, such as optimising blood pressure control in people who have had a stroke or TIA, and anticoagulation of those at higher risk of stroke.