How this PCN provides a one-stop-shop for hypertension

A PCN in London set up a hypertension diagnosis clinic which works at scale to run searches from a central point to find patients who may have undiagnosed hypertension. Two years on, the clinic is self-sufficient and there are plans to expand the service. PCN manager Amy Sefton explains

The Wandle PCN hypertension diagnosis clinic was set up in 2021. At the time, cardiovascular disease (CVD) was a meaty investment and impact fund (IIF) target and we saw it as an opportunity to work at scale and achieve the target without putting additional pressure on practices.  

Essentially, the clinic works at scale across the PCN in London to run searches from a central point to find patients who have had a previous high blood pressure (BP) reading but no diagnosis of hypertension.

We then invite them to do a seven-day home BP reading using one of our monitors and then process the results centrally, inviting any patients with a high BP back for a ‘one-stop shop’ appointment for further testing and diagnosis.

As a result of the clinic, the PCN achieved the full IIF payment for the hypertension diagnosis targets, which then enabled the clinic to continue. Now, the clinic is self-sufficient and sustainable by using funds won through meeting the IIF cardiovascular disease (CVD) targets. 

Aims

The aim was to offer patients and practices a ‘one-stop-shop’ approach to finding and diagnosing hypertension. We wanted to create a service that was centrally managed for efficiency and completely independent from individual practices to relieve the workload burden on them.

We also wanted to save patients from attending multiple appointments by creating a service with enough time per appointment to conduct all necessary testing and support for patients. As we had been given a batch of BP machines for home use, we could use them as part of a wider diagnostic service.

I came up with the idea for the clinic and set it up with input from our clinical director. We now also have a part-time PCN care coordinator working on this project, among others. She manages the central PCN email inbox and keeps track of patients who are on the hypertension diagnosis pathway to ensure she checks in with them for follow-up and escalates as appropriate.

Methods

At first, we set up some pop-up stands in our Covid vaccination centre to get patients to record their BP. We also ran searches in the practices’ Emis systems to identify patients who had a previously high BP reading, but no diagnosis of hypertension.

We then sent text messages to those patients, encouraging them to get a free BP check – in the surgery waiting room, at a community pharmacy or at home – and send their BP reading to a centrally managed e-mail inbox we had set up.

Eventually, we upgraded this system to send AccuRx questionnaires whereby patients could input their BP readings directly to be coded onto their record. The e-mail option remains open for those without smartphones. And we allow patients to drop off a handwritten reading to the practice if preferred. If patients are non-responsive to the various options, we phone them.

To ensure we are giving all patients a way to participate and being mindful of the need to tackle health inequalities, we offer free BP check appointments at the clinic for those who are not able to record their own. We also send non-responders a self-booking text message to make it as easy as possible for them to book a check-up at the clinic.

We operate the clinic twice per week in two practices to give patients choice. We have a nurse and a physician associate running the sessions, but our paramedics can also visit housebound patients if they need the service. Otherwise, for the BP monitoring, we loan machines to patients who need them, and then they are encouraged to self-monitor at home.

Using this process, we have had some great results. We have set up a group health and wellbeing coaching session online for newly diagnosed patients to support them with lifestyle changes.

For efficiency, we use a central PCN Emis system and created two separate appointment types. There are 10-minute appointments for an initial consultation with the nurse or for patients to collect or return a loaned BP machine. Then, there is a subsequent 30-minute appointment for all the diagnostic testing, which can be booked if their seven-day home readings have shown as high.

The clinician can then code the diagnosis of hypertension and make recommendations to the patient for lifestyle changes and support. They then send a task back to their own practice to get their practice pharmacist or GP to prescribe medication or call the patient for follow-up.

Once we felt we had a really good system and pathway for patients, we extended the text messaging to patients with no BP recorded in the last five years to capture an even wider cohort of patients.

Outcomes

In 2022/23, we excluded or diagnosed hypertension in 1,243 patients through this pathway and overall increased the hypertension register by 0.83% across the PCN. Our method of texting and contacting patients for up-to-date BP readings likely reached even more patients than this, but this is the number picked up on the relevant IIF search.

The increase in diagnoses is clearly a positive for patients as it means they are now able to get the care they need. There’s nothing more satisfying than proactively catching a patient who was unknowingly walking around with high blood pressure and offering them support.

Running as a fully centralised PCN service, practices are saved from the burden of this work and patients benefit from the proactive approach to healthcare. Taking a central approach means we’ve also been able to help practices with their case finder searches and correct any coding, increasing the accuracy of their data and population health management.

Feedback from patients is that they appreciate the one-stop-shop approach and the ease with which they can submit their BP readings via AccuRx.

The initiative is very low cost. The set-up cost was minimal because we were provided with machines for a BP at Home project, which we then developed into this service. And the ongoing costs are low too – we pay for a locum nurse at one site and pay for the text messaging. The PCN also pays the practice a small fee to use their room for half a day, whilst the physician associate and care coordinator are ARRS-funded.

Although we have a central team, it is more integrated into practices than a secondary service, so they are well-placed to ensure any required follow-up is escalated.

Of course, with anything new there are challenges. This is mainly around communicating with practice teams about the booking process so they can advise patients. We also encourage them to promote the service to patients. And we remind them of the importance of correctly coding BPs in patient records so that we can easily run searches.

In short, these are the usual challenges of having a human workforce, which means that there are bound to be errors and inconsistencies.

Future

Although the IIF target isn’t the same this year, we have continued with the clinic.

We are also looking at whether we can use this clinic to tackle health inequalities by identifying the patients who do not respond to the invitation text messages or have difficulty accessing BP machines.

We plan to expand the clinic to support patients who want help with weight management or lifestyle changes. And we are also looking at any opportunities to bridge the gap with secondary care.

Finally, we plan to promote the service with campaign materials to reach as many patients as we can. There will be greater visibility around the waiting room BP machines to boost their usage, and we will run PCN health check events.

Amy Sefton is Wandle’s PCN manager and digital transformation lead.