Pharmacy hypertension referral: positive for patients and primary care

I have a passion for the clinical area of hypertension, mainly because this is one of the most poorly diagnosed conditions nationwide. As many as 5 million UK adults have undiagnosed high blood pressure. 

If it is diagnosed early and managed appropriately, there are clear health outcomes that support long-term cardiovascular health, reducing the burden of disease, the risk of hospital admission and supporting the aims of the NHS Core20PLUS5 approach to reducing health inequalities. 

According to the NHS, cardiovascular disease (CVD) accounts for one-fifth of the life expectancy gap between England’s most and least deprived communities. Hypertension is a key risk factor for CVD and the NHS estimates it affects one in four adults, half of whom are undiagnosed or have uncontrolled blood pressure. It adds: “A 10mmHg reduction in blood pressure results in a reduced risk of coronary heart disease (17 per cent), stroke (27 per cent), heart failure (28 per cent) and all-cause mortality (13 per cent).”

A recent 12-month pilot scheme implemented at one of my GP surgeries last October set out to support usage of the community pharmacy hypertension case-finding service. The surgery has approximately 7,000 patients and is situated in an area with poor monitoring and management of hypertension because of its demographic. 

For the pilot, the ICB and my senior colleagues implemented a new and unique additional function within the EMIS PMR system to enable the surgery to create electronic referrals/signposting to local pharmacies for blood pressure monitoring.

The aim was to improve the poor detection and monitoring of hypertension locally. However, it was clear from the start that funding for this additional EMIS function was not indefinite and continued funding would be dependent on the pilot’s outcomes. 

Engagement

I was given lead responsibility to implement the pilot – a valuable and exciting opportunity. In order to yield the most significant and impactful outcomes, I felt that collaborative engagement was required from all clinicians within the practice.

I approached this through discussions with the clinicians and GP partners at a clinical meeting and explained the rationale for the introduction of this referral pathway and its importance to the local population in supporting the diagnosis, monitoring and management of hypertension.

Like all general practices, our team comprises a diverse team of clinicians and it was paramount that the wider team was aware of this function and recognised its ability to support hypertension prevalence and monitoring. The clinicians and I discussed how we could use the referral pathway to help support patient care and improve efficiency of workload. All clinicians at the practice were proactive and started using the pathway without delay. 

I developed a user guide on how to implement the new referral function, including a section to allow supportive information to be communicated to the pharmacies, providing context and background to the referral. 

Outcomes

I reviewed the data captured from the referrals to community pharmacy for clinic blood pressure (BP) and ambulatory blood pressure (ABPM) for the 12 months between October 2023 and October 2024, and followed up on the outcomes of these with regard to diagnoses and monitoring. A total of 244 patients (96 for clinic BP and 148 for ABPM) were referred to pharmacy during the 12-month period.

Of the patients referred to local pharmacies for clinic blood pressure reading, 38.5 per cent had a normal reading. However, many had been referred due to a high clinic BP reading at the GP surgery. These pharmacy referrals reduced the risk of medicines dosage increases or new additional antihypertensive treatments. This in turn reduced the risk of avoidable harm (i.e. hypotension/falls risk and potential hospital admission) if the high readings had been acted upon within the GP surgery.

This demonstrated that the hypertension case-finding service could provide support for patients with ‘white coat syndrome’, which, as demonstrated by the data above, some patients may experience within a GP setting only. 

“From the referrals to pharmacies during the pilot, 18 new patients were diagnosed with hypertension”

Just over 73 per cent of referrals completed to community pharmacy for clinic BP checks were to support readings that were overdue at the surgery and to support appropriate drug monitoring. This supported the practice’s quality and outcomes framework (QOF) and the safe monitoring of medication as per patient safety and Care Quality Commission requirements. 

Being more aware of referring patients to community pharmacy for BP monitoring enabled the surgery to explore the option of other cohorts of patients also being referred (e.g. those over 45 years of age with no blood pressure readings within the last five years).

From the referrals to pharmacies during the pilot, 18 new patients were diagnosed with hypertension – the equivalent of between one and two new diagnoses every month. These patients were offered lifestyle advice and antihypertensive treatment as appropriate, in line with NICE guidelines.

Additionally, six patients received optimisation of their current antihypertensive medication because of the ABPM completed by the pharmacies and two were referred onwards for potential atrial fibrillation (AF) diagnosis via symptom review and electrocardiogram.

Outlook

Overall, of the referrals to community pharmacy for ABPM, 17.5 per cent had a significant outcome. Therefore, by replicating this model, GP surgeries with a greater patient population than ours have the potential to achieve a significant impact in increasing hypertension and AF diagnosis.

The electronic referral process utilised in this pilot demonstrated a more robust method of referral than verbal communication to the patient. It also ensured that the pharmacies were able to manage the demand for appointments and improve the overall patient experience. 

The provision of the pharmacy hypertension case-finding service was a significant aspect of the success of this pilot scheme. 

Without referral to community pharmacy, the patients would have had their clinic BP and ABPM completed at appointments at the GP practice. This would have represented 392 appointments – all of which were saved thanks to the case finding service. During the pilot, 32 appointments were saved each month within the practice.

These were used to support long-term condition reviews for patients, thus improving monitoring of patients, distribution of resources and accessibility for patients within the surgery. 

Our ICS head of community pharmacy services will be sharing the data from the pilot project to support the continued funding of the electronic referral scheme as well as the addition of an initiation and maintenance tab for oral contraception supply in the future.

• Gurvinder Najran works within general practice in Dudley, West Midlands and is Black Country ICB/Dudley PCN engagement lead.