Cardiovascular disease (CVD) is the biggest cause of early death in deprived areas of England and at least half of all heart attacks and strokes are linked with high blood pressure, known as hypertension. It is easy to measure and can even be done at home. Yet, an estimated six million people nationwide have high blood pressure and don’t know it.
Technology has put vast swathes of personal health data at our fingertips. We can monitor our weight, track exercise, measure sleep, count calories, so why don’t we routinely check our blood pressure? It is a question that has informed some of the thinking behind the NHS’s Core20PLUS5 initiative to tackle health inequalities, which places hypertension case-finding among five priority clinical areas. Indeed, NHS England believes it can save 150,000 lives through better control of CVD, describing it as “the single biggest area where the NHS can save lives over the next 10 years”.
It is a condition that disproportionately affects the less well off, with people from England’s most-deprived areas 30 per cent more likely to have high blood pressure and four times more likely to die from cardiovascular disease, compared with the least deprived. Black and minority ethnic people are also disproportionately affected.
Professor Maggie Rae, Trustee Elect of the Royal Society of Medicine and President of the RSM’s Epidemiology and Public Health Section, said: "We must get to the most deprived people.
"If we just target the general population, we'll probably widen health inequalities because the people who have the aptitude and time to take up the offers are usually the better off people.
“I want everyone to be healthy, but I don't want the rich being healthy at the expense of the poor.”
Changing the culture around monitoring is vital, according to Professor Nik Patel, Chair of the Academic Board at the Royal Society of Medicine and a senior consultant cardiologist. He said: “Up to 30 per cent of the adult population could have hypertension, many of whom have been not diagnosed. That's the real difficulty.
“Most people don't feel ill and, therefore, unless you actively look for it, you won't find it.”
The NHS, via its Long Term Plan, has reviewed successful initiatives in other countries that have increased people’s awareness of their own blood pressure readings. These campaigns encourage individuals to ‘know their ABCs’ (atrial fibrillation (AF), blood pressure and cholesterol).
Dr Shahed Ahmad, NHS England’s National Clinical Director for Cardiovascular Disease Prevention, said: “We need to have a wider conversation with the public on understanding why blood pressure is important and the importance of controlling it.”
But it's not just education that is needed; the right people need the right tools in the right places. Dr Ahmad continues: “We need to continue to provide community leaders with guidance and resources on innovative ways of reaching patients.
“From health checks in high-street pharmacies and blood-pressure monitors at home, to partnerships with the third sector, there are many opportunities to support CVD prevention.”
In England, there has already been a move towards locating blood-pressure monitors in GP surgeries and waiting rooms. NHS England is expanding this activity into other community settings, such as dentists and pharmacies.
The plan is already beginning to pay off. Since October 2021, more than 6,000 community pharmacies have signed up to offer free blood pressure checks for over-40s. More than 18,000 people had a blood pressure check in the first three months of the service going live, with patients’ readings recorded and shared with their GP practice.
NHS England is also helping people to manage their own blood pressure through the provision of 220,000 home monitors and supporting GP practices to integrate home readings into their management of hypertension. However, to achieve widespread cultural change, we will need to, as Professor Rae puts it, “industrialise the scale” and encourage those with the means to buy their own kit (this is relatively inexpensive online - the British Heart Foundation sells a range of approved blood-pressure monitors, costing as little as £19.99).
The NHS is understandably focused on uncovering as many of these hidden cases as possible but the healthcare interventions that follow are equally important. On the surface, many of the measures are simple: better diet, more exercise, quitting smoking and cutting down on alcohol. Yet, preparing healthy meals and keeping fit takes time; time that may be in scant supply for someone struggling to make ends meet. The impact of a stressful life should not be underestimated.
To get good control of high blood pressure, people usually need to take multiple medications, and non-compliance is a big barrier. We need to overcome this cultural aversion, argues Professor Rae. She said: “I'm all for lifestyle changes. Get more active, drink less alcohol, lose some weight. Do all those things.
“But we could prescribe medication that would help them while they do the rest of the stuff. Then they simply wouldn't have high blood pressure because it would be controlled.”
NHS England knows that widespread monitoring of blood pressure across the country has the potential to be our canary in the coal mine, allowing us to detect and intervene in a major risk factor for some of the deadliest and disabling diseases affecting the population. That in turn would lengthen lives, reduce pressure on the NHS, save money and reduce inequalities. But behavioural and systemic change on this scale is never easy and will require co-ordination and enthusiasm from across the healthcare profession and beyond.
The Royal Society of Medicine has launched a major multi-year programme to tackle health inequalities and is holding a flagship conference on 11 January 2023, in partnership with NHS England. Dr Ahmad, Professor Patel and Professor Rae all will be speaking at the conference.
This is the fourth in a series of features in support of the RSM’s Tackling Inequalities programme. Each examines health inequalities through the lens of different RSM sections. This article focused on hypertension case-finding and featured the Epidemiology and Public Health Section. Thank you to all contributors.
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