Associate Feature: The pressure is on
Reducing demand on the creaking NHS might seem impossible as the population ages.
But there is a relatively simple way, doctors believe: tackling high blood pressure.
Brian McKinstry, a GP and emeritus professor of primary care e-health at the University of Edinburgh, believes that bearing down high blood pressure could be transformative.
“We have got something here that is the biggest cause of heart attacks and strokes. We also have treatments that make it better.
“All we have to do is get the treatments to the patients.
“High blood pressure is by far the biggest thing in health – if we could control it, the impact on the health service would be phenomenal. It would reduce strokes, heart attacks, dementia, renal failure and heart failure.
“If you could reduce heart failure by 40 per cent, which is what we think would happen if we controlled all high blood pressure, then that alone would have a tremendous effect.”
Yet in spite of this, high blood pressure is nowhere near as well managed as it could be.
Of the 1.3 million people estimated to be living with high blood pressure in Scotland, 500,000 are thought to be undiagnosed. In many others, the condition is poorly controlled, according to BHF Scotland.
The estimated cost of the condition to the NHS is £800m a year, with half of heart attacks and strokes associated with it.
If blood pressure were optimally treated in Scotland, BHF Scotland estimates that around 4,900 heart attacks and 5,100 strokes could be prevented over 10 years. That alone would save the NHS £90m.
So why isn’t it better managed?
High blood pressure often has no symptoms, so some people don’t know they have it. One priority is to create more opportunities for people to test their blood pressure in the community.
Dr Chris Williams, joint chair of the Royal College of GPs in Scotland, is a family doctor in Grantown-on-Spey. He says that where people have blood pressure monitors in their own home, they sometimes find out for themselves that they have the condition. They then bring it to the attention of their GP, instead of the other way round.
“That is a positive change,” he says. “We want to move away from the idea that the GP consultation room is where high blood pressure is discovered.”
In February, the chief medical officers of all four UK nations made a joint call for more blood pressure testing in workplaces and other non-NHS settings. Pharmacies, mobile vans and even some barber shops are examples of places where this has been done. “The problem there is that a barber is not able to give medical advice,” notes Williams. “But it’s better that it is discovered.” People can then seek medical advice.
Receiving a high blood pressure reading is only the first step, though. Reducing it once it’s been identified is critical but getting patients to stick to their medication regime isn’t always easy.
“A lot of people find it hard to believe that they really need to take medication at all,” explains McKinstry.
“You say to someone they need to go on one drug, no two drugs, maybe even three drugs, and they think, ‘but I don’t feel sick at all’. So it’s kind of difficult sometimes to persuade people to take the medication.”
McKinstry is a big advocate of telemonitoring, where people are given machines to measure their blood pressure at home. They can then send in the readings via an app, text, or through the keypad of a touchtone phone, so that the GP surgery can monitor them. If patients don’t input their readings at the expected time, they get digital reminders.
McKinstry says: “If you’re a patient and you have one blood pressure reading that’s a little bit high, people will say things like ‘I had a row with my husband before I came out this morning’, or ‘the bus was late’. So often the doctor or nurse will say, ‘well, let’s leave it a few weeks or months and we’ll test it again’.
“But if you’re sitting at home and you’re relaxed and you have 20 blood pressure readings and all of them are high, then it’s very hard to hide from that.
“We’ve got some qualitative work that shows people are more likely to adhere to their medication when they are checking their blood pressure at home because they can see when they don’t take it that their blood pressure goes up.”
Williams agrees that a set of home readings is far better than a small number of readings at the surgery. “People are much more likely to embark on the treatment if they have those numbers,” he says. “Some participation in the treatment is very useful.”
Some 1.2 million primary care appointments every year are just for measuring blood pressure. Research shows that telemonitoring reduces face-to-face consultations by almost a quarter per patient. McKinstry says: “That works out at about one less consultation a year per patient. We’ve got one practice in Edinburgh that has nearly 1,500 patients using the system, so if they are saving 1,500 appointments a year, that’s a massive saving.”
Investing in tackling blood pressure pays for itself, say campaigners.
The Scottish Government has already accepted the need for better blood pressure monitoring. It launched the Scale Up BP trial to test out the use of telemonitoring using funding from the Technology Enabled Care programme launched in 2016. This has since evolved into the Connect Me telemonitoring system. “It’s a moving landscape,” says Williams. “The technology over time has become more usable, it can communicate better and the functionality has improved.”
Much has been achieved. It is thought that a bigger proportion of the population uses telemonitoring to manage their blood pressure in Scotland than in any other country in the world.
Yet with so many with high blood pressure undiagnosed or poorly controlled, there is much more to do. Around 60 per cent of GP practices have at least one patient using telemonitoring but surgeries vary significantly in how much they use it.
In 2019, an inquiry into high blood pressure by the cross-party group on heart disease and stroke recommended improving community-based detection and medicine adherence, and increasing the use of self-monitoring.
But campaigners are worried about the lack of progress during the pandemic and since. This is in spite of the publication of a Heart Disease Action Plan in 2021 which named tackling risk factors like high blood pressure as priority number one.
The Scottish Government has in the past paid for tens of thousands of home blood pressure machines, but is not doing so any more.
McKinstry says: “There is still money for the telemonitoring system but no money now to support buying blood pressure machines and some health boards are having difficulty finding the money to support the project in their area.”
He would like to see ministers provide ongoing funding for the machines, which cost £15-£18 each, noting that while some people can afford to buy their own, many cannot.
“The poorest people won’t have a blood pressure machine,” says McKinstry. “And if you’re faced with the choice of paying the gas or electricity bill, or buying school uniform, are you going to find the money for a blood pressure machine?
“It’s so unfair because this is the group that are most likely to benefit, and they are the ones who are least likely to have one.
“You have to find a way that the NHS provides these machines.”
Isla Mackenzie, professor of cardiovascular medicine at the University of Dundee, also supports the use of blood pressure monitors at home.
She says: “It can be very helpful for patients to self-monitor and that’s something to be encouraged. Empowering patients this way is really important.
“Telemonitoring is one way – there’s also the possibility of them measuring it at home and writing it down and seeking help from the GP or nurse when they see the numbers going up consistently. For instance, this might work for long-term patients, measuring it intermittently at home, with guidance from health professionals.
“If we were able to give out more blood pressure monitors for people to keep, that would be really useful.
“That’s somewhere where the Scottish Government could make decisions that would really help people.”
She stresses that lifestyle advice, such as on smoking cessation, healthy eating and exercise, is also important. Even so, tackling high blood pressure should be a priority because it affects so many people and is an easily identifiable risk factor.
BHF Scotland wants to see renewed focus now on tackling high blood pressure.
Jon Roden, policy and public affairs manager at the charity, says: “We would like the Scottish Government to prioritise addressing high blood pressure with investment. The figures show that over the next 10 years there’s the potential to prevent many thousands of heart attacks and strokes. What’s needed is to bring together the NHS to galvanise a response.”
McKinstry believes greater use of telemonitoring could be critical: “The evidence is absolutely unassailable now. You’ll never find anyone saying the jury’s out or we need to do more research. Everyone admits that this works.
“All we have to do is put it into practice.”
This article is sponsored by British Heart Foundation Scotland