Using digital tools in community pharmacy to identify cases of undiagnosed hypertension

The ‘NHS community pharmacy blood pressure (BP) check service’ was commissioned as a community pharmacy advanced service in October 2021​[1]​. Following this, Community Pharmacy Surrey and Sussex worked with NHS Sussex to develop a pathway to maximise the use of the service and increase the detection rate of undiagnosed hypertension.

Hypertension can increase the risk of coronary artery disease, stroke and chronic renal disease. It is important to detect hypertension because it is often asymptomatic. 

In May 2022, a referral pathway was developed to support the delivery of the community pharmacy hypertension case-finding service​[2]​. This pathway aimed to enable cohort identification, promote patient choice, facilitate primary care network (PCN) collaboration, as well as utilisation of the advanced service. Importantly, capacity within pharmacies to deliver this service was assessed and subsequently matched to the capacity within PCNs to manage new diagnoses of hypertension. For this initiative, the cohort of patients was defined as those who had not had a BP check in the past five years or those that had been identified as having a raised BP reading but were not on a hypertension register at their GP surgery​[3]​.  

A complete package of support was designed, which included: 

• ‘How to’ guides;
• Links to text messaging used in the pathway, as well as suggested text message content;
• Information on how to complete cohort searches;
• Suggested cohort identification;
• Pharmacies contacted and confirmation obtained that the national service is live;
• Pharmacy contact information;
• Link to Google Map of pharmacy information to embed within the text message;
• Ongoing support if required;
• Pathway document​[4]​. 

Community Pharmacy Surrey and Sussex contacted pharmacies in the implementation phase to ensure that pathway implementation was possible. This included checking how many pharmacies were ‘live’ in the PCN and the capacity of the pharmacy (i.e. how many appointments the pharmacy could offer to patients). This was used to determine how many text messages were initially sent out. This was initially 20–25 texts weekly per pharmacy ‘live’ with the service. The volume of texts sent out was then increased as more pharmacies went ‘live’ or when workload impact was assessed as minimal.  

Information that had been sourced was added to the patient community pharmacy map to advise patients of service availability times, the patient was then able to make an informed decision regarding their healthcare​[5]​. The Google Map link is embedded within the text message, so patients can only visit or contact those pharmacies who are able to offer this service. The maps created are specific to each integrated system by Community Pharmacy Surrey and Sussex. 

Once the referral pathway is in place, a GP clinical lead or another designated healthcare professional colleague identified a cohort of patients that met their target requirements using search criteria in their computer systems. A PCN administrator invited these eligible patients via AccuRx to either complete a BP check at home or visit a participating pharmacy. AccuRx is a digital enabler that can send bespoke secure text messages to patients​[6]​. Using cohort searches, patients are invited to record a BP result, text messaging includes a secure link to enter the result either using a home BP monitor or to visit a participating pharmacy​[7]​.  

The pharmacist conducts the service as per service specification, the pharmacy records the clinical interaction and follows their reporting process as outlined in the specification​[8]​. The patient inputs the result on their smartphone using the secure link, this message is sent directly to the surgery and coded into patient records. 

The pharmacist will offer the patient ambulatory blood pressure monitoring (ABPM) if clinically indicated and the result shared with the GP practice. If the patient declines APBM, this is communicated back to the GP surgery and the patient will be sent a bp@home seven-day BP Florey (text message) via AccuRx. The request for multiple BP readings is in line with National Institute for Health and Care Excellence guidance​[9]​.  

In Sussex, there were three place-based pilot sites collating data to enable evaluation of the pathway, which resulted in 2,683 text messages being sent. A total of 1,519 responses were received, equating to a response rate of 56.6%. Of the respondents, around half chose to attend a pharmacy for further intervention and half of the respondents had access to their own BP monitor.

From the place-based pilots, 77 patients were newly diagnosed with hypertension and treated to target. Sussex is our flagship area with the highest uptake of GP practices and PCNs participating.  

The pathway has been used to successfully detect undiagnosed hypertension using digital technology to increase capacity for BP management across primary care. It has also been used to treat hypertension to target thresholds. This supports primary and secondary prevention in primary care​[10]​. There is the opportunity to signpost patients such that they may engage with lifestyle services, such as smoking cessation. Recognising pressures on the GP workforce, the pathway was designed so that GP review is only needed once hypertension has been diagnosed. This means that further investigations as needed and pharmacological management may be initiated by the patient’s own GP.  

This pathway has created an opportunity to link the community pharmacy BP check service with bp@home initiatives, as well as health inequalities work. For the latter, we have actively engaged with those GP practices and PCNs in the most deprived areas of Sussex that are not achieving targets as per quality and outcomes framework data and those with increased levels of personalised care adjustments or exception reporting.

Importantly, teams have been able to build relationships across primary care for the benefit of patients with a patient-centred approach. We believe this is the first time we have seen collaboration in this way linking primary care services with community pharmacy initiatives. We have received positive feedback from the 9 PCNs and 38 practices we have supported with this work. 

As the pathway continues to roll out, we will see the expansion of cohort identification and the utilisation of digital tools to support the delivery of high-quality healthcare to the population, and the delivery of the priority objectives outlined in the ‘NHS long-term plan’, such as empowering people, supporting health and care professionals, supporting clinical care, and improving population health.  

The vision remains that this becomes a ‘business-as-usual activity’ and is the start of the journey towards a fully inclusive, digital, collaborative primary care team.  

Marie Hockley, deputy chief officer at Community Pharmacy Surrey and Sussex; and Suneeta Kochhar, clinical lead for CVD prevention at NHS Sussex