The 5-year Community Pharmacy Contractual Framework (CPCF) agreement reached in July 2019 included a plan to pilot case finding for undiagnosed cardiovascular disease.

In 2020, NHS England and NHS Improvement (NHSE&I) commenced a pilot involving pharmacies offering blood pressure checks to people 40 years and over. In some pharmacies within the pilot, where the patient’s initial blood pressure reading was elevated, they would be offered 24 hour ambulatory blood pressure monitoring (ABPM), which is the gold-standard for diagnosis of hypertension.

Following the initial findings of the pilot, the Department of Health and Social Care (DHSC) and NHSE&I proposed the commissioning of a new Hypertension case-finding service, as an Advanced service, in the Year 3 negotiations.

Read the PSNC news story announcing the CPCF arrangements for 2021/22

Cardiovascular disease (CVD) is one of the leading causes of premature death in England, affecting seven million people and accounting for 1.6 million disability adjusted life years.

This places a financial burden on the NHS of approximately £9 billion per year.

Hypertension is the biggest risk factor for CVD and is one of the top five risk factors for all premature death and disability in England.  An estimated 5.5 million people have undiagnosed hypertension across the country.

CVD is a key driver of health inequalities, accounting for around 25% of the life expectancy gap (27% in men and 24% in women) between rich and poor populations in England. Those in the most deprived 10% of the population are almost twice as likely to die as a result of CVD than those in the least deprived 10% of the population. Additionally, 60% of excess mortality for those living with severe mental illness can be attributed to preventable physical health conditions, such as heart disease.

Residents of the most deprived areas in England are 30% more likely to have high blood pressure (BP) compared to those in the least deprived areas . Community pharmacy BP monitoring has the potential to increase the detection of hypertension within local populations and is expected to positively impact health inequalities by targeting people who do not routinely see their GP or use other NHS services.

The NHS Long Term Plan commits the NHS to reducing morbidity and mortality due to CVD, tackling inequalities and a shift towards prevention strategies. It specifically states that community pharmacy, in collaboration with other providers, will provide opportunities for the public to check on their health through tests for high BP and other high-risk conditions.

In February 2019, as part of the Cardiovascular Disease Prevention System Leadership Forum, NHSE&I published new national ambitions for the detection and management of the high-risk conditions. The ambition for hypertension is that 80% of the expected number of people with high BP are detected by 2029, and that 80% of the population diagnosed with hypertension are treated to target. At the time of publication of the NHS Long Term Plan, NHSE&I and Public Health England (PHE) estimated less than 60% of people with hypertension had been diagnosed.

The aims of the service

The service aims to:

• Identify people with high blood pressure aged 40 years or older (who have previously not had a confirmed diagnosis of hypertension), and to refer them to general practice to confirm diagnosis and for appropriate management;
• At the request of a general practice, undertake ad hoc clinic and ambulatory blood pressure measurements; and
• Provide another opportunity to promote healthy behaviours to patients.

Introduction of the Advanced service will support the work that general practices and wider Primary Care Network (PCN) teams will be undertaking on CVD prevention and management, under changes to the PCN Directed Enhanced Service which will commence on 1st October 2021.

From that date, PCNs must improve diagnosis of patients with hypertension, in line with NICE guideline NG136, by ensuring appropriate follow-up activity is undertaken to confirm or exclude a hypertension diagnosis where a blood pressure of ≥140/90mmHg in a GP practice, or ≥135/85mmHg in a community setting, is recorded.

As part of this, PCNs must work pro-actively with community pharmacies to improve access to blood pressure checks, via the hypertension case finding service.

In 2022/23, PCNs must ensure processes are in place to support the exchange of information with community pharmacies, including a process for accepting and documenting referrals between pharmacies and GP practices, in relation to the hypertension case finding service.

Read more about the changes to the PCN requirements in PSNC Briefing 035/21

The service requirements are included in the service specification, which contractors must read before deciding whether to provide the service.

Download the service specification

Service Directions & Determination
The Secretary of State Directions provide the legal basis for the provision of the service.

Download the service pathway

PSNC Briefing 041/21: Guidance on the Community Pharmacy Hypertension Case-Finding Advanced Service
This PSNC Briefing provides additional guidance for community pharmacy contractors and their teams on the service.

The service has two stages – the first is identifying people at risk of hypertension and offering them blood pressure measurement (a ‘clinic check’).

The second stage, where clinically indicated, is offering 24 hour ambulatory blood pressure monitoring (ABPM). The blood pressure test results will then be shared with the patient’s GP to inform a potential diagnosis of hypertension.

Contractors opting to provide the service must undertake both stages of it, where clinically required, i.e. it is not possible to just undertake clinic BP readings and not ABPM.

To start with, the service will only be provided by pharmacists, however if changes to the VAT rules can be agreed between DHSC, HM Revenue and Customs and HM Treasury, to ensure pharmaceutical services provided by other staff, but under pharmacist supervision are VAT exempt, the service will be modified to allow better use of skill mix.

As part of preparations to provide the service, contractors will need to purchase or rent equipment for each of the two stages of the service – Clinic blood pressure check and 24-hour ABPM – unless they already have equipment which meets the required standards.

Equipment that is to be used in the service must be validated by the British and Irish Hypertension Society (BIHS), so contractors must use a ‘normal’ BP meter and an ABPM which are included on one of the two following BIHS lists:

Validated BP Monitors for Home Use

Validated BP Monitors for Specialist Use

Points to note:

• ABPMs must be reset for each service user;
• To meet the service specification requirements, validation, maintenance and recalibration of both clinic blood pressure monitors and ABPM devices should be carried out periodically according to manufacturers’ instructions; and
• Infection control measures and cleaning must be carried out as per the instructions of the manufacturer or supplier and in line with current infection control guidance.

Considerations before purchasing/renting equipment

Contractors may find it useful to refer to the Medicines and Healthcare products Regulatory Agency guidance on the purchase, management and use of blood pressure measurement devices and the Point of care testing in community pharmacies guide when selecting equipment for this service.

Before a decision is made about the purchase or rental of equipment, there are several considerations contractors may need to think through to ensure they have weighed up the additional requirements, implications and costs associated with provision of the service when using their selected equipment.

A non-exhaustive list of some of the considerations can be found below:

• Is maintenance and training included in the purchase price?
• If equipment is broken, does the supplier provide a spare whilst it is being repaired?
• Calibration versus replacement cost and the carbon footprint of both activities;
• Frequency/cost of cuff replacement and other consumables;
• Complexity of use – time taken to use (and explain use, in the case of ABPM);
• For clinic meters, do they automatically take 3 measurements and flag irregular pulse (this feature is very beneficial, but optional)?
• For ABPM, the usability of any inclusive software to support set up for the patient and interpretation of readings. Additionally, software and hardware compatibility with existing pharmacy IT systems needs to be considered, e.g. can you plug the meter into a USB port on a PC in the pharmacy; and
• Insurance to cover accidental damage to either type of meter and to cover the theft or failure of a patient to return ABPM.

Training requirements

To provide the service, pharmacists must:

• Be familiar with the NICE guideline Hypertension in adults: diagnosis and management [NG136];
• Have read and understood the operational processes to provide the service as described in the service specification; and
• Have completed the recommended training on how to use the blood pressure monitoring equipment which should be provided by the equipment manufacturer/supplier.

Additional optional training

Pharmacists wanting to undertake further training on hypertension, understanding vascular risk and behaviour change interventions can do so on an optional basis to support their own continuing professional development (CPD).

Support with additional CPD can be found on the CPPE hypertension gateway page of the CPPE website.

Pharmacy Team training

The whole pharmacy team can proactively promote this service and support with the recruitment of patients. Teams should be briefed on the service and coached on how to best approach people about the service.  A pharmacy team briefing and a guide on how to recruit patients is available to assist contractors to engage and coach their team members.

Download the PSNC Briefing for pharmacy teams on the service

Sign up to provide service

Contractors must notify NHSE&I that they intend to provide the service by completion of an electronic registration through the NHS Business Services Authority’s (NHSBSA) Manage Your Service (MYS) application.

Standard Operating Procedure

Contractors must have a Standard Operating Procedure (SOP) for the service, which all staff participating in provision of the service must be familiar with and follow. SOPs must include the process for maintenance and validation of the equipment used.

Various pharmacy support organisations provide template SOPs which their members can personalise for use in their pharmacy.

Engagement with local GP practices and/or PCN colleagues

Prior to provision of the service, contractors must engage with local general practices and/or PCN colleagues to make them aware the pharmacy is participating in this service.

Practices may want to refer patients to the pharmacy for blood pressure checks (clinic blood pressure checks or ABPM). Where practices wish to use this facility, contractors should agree a local process with the practice by which this will work. There are no specific requirements set for this process and it could involve the practice agreeing that a specific list of patients can access the service or a cohort of patients could be specified.

A letter / email template to support contractors to notify GP practices that the pharmacy will be providing the service is available.

Download the GP letter / email service notification template  (Microsoft Word)

A briefing to provide information for general practice teams on the new Community Pharmacy Hypertension Case-Finding Advanced Service is available to assist contractors to engage their local general practice colleagues.

Download the PSNC Briefing for general practice teams

Contractor checklist

Once a contractor has decided they wish to provide the service, PSNC’s implementation checklist will guide them through the steps they need to take to prepare to provide the service.

Download the Hypertension Case-Finding Contractor implementation checklist

The service specification lists the following inclusion and exclusion criteria for the service:

Inclusion criteria

• Adults who are 40 years old or over, who do not have a current diagnosis of hypertension;
• Patients, by exception, under the age of 40 who request the service because they have a recognised family history of hypertension may be provided the service at the pharmacist’s discretion;
• Patients between 35 and 39 years old who are approached about or request the service may be tested at the pharmacist’s discretion; and
• Adults specified by a general practice for the measurement of blood pressure (clinic and ambulatory blood pressure checks). This process should be agreed locally with general practices.

Exclusion criteria

• People who are unable to give consent to participate;
• People under the age of 40 years old, unless at the discretion of the pharmacist or unless they have been specified by a general practice for the measurement of blood pressure; and
• People who have their blood pressure regularly monitored by a healthcare professional, unless the general practice requests the service is provided for the patient. Requests should be sent via a process which is agreed locally with general practices.

General practice referrals

If practices want to refer patients who have already been diagnosed with hypertension for blood pressure checks, then contractors should work with their practices to agree a local process by which this will work; there are no specific requirements set for this process and it could involve the practice agreeing that a specific list of patients can access the service or a cohort of patients could be specified.

General practices will also be able to refer patients requiring ABPM; in this scenario it is recommended that this referral is made electronically to the pharmacy.

Download a practice referral template (Microsoft Word)

Download a practice referral template (PDF)

Promoting the service

Contractors who will be providing the service can use a poster and, where facilities exist, digital marketing resources to advertise the availability of the service in the pharmacy.

Download the poster (PDF)

Download the digital marketing resources (PDF)

Small flyers to use on prescription bags etc. (Microsoft Word)

Small flyers to use on prescription bags etc. (PDF)

Template patient leaflet to promote the service (Microsoft Word)

Patient leaflet to promote the service (PDF)

A patient recruitment guide is available for the pharmacy team, containing tips on how to successfully recruit patients using some of the insights from pilot sites is available as part of the briefing for pharmacy teams on the service.

Download the PSNC Briefing for pharmacy teams on the service

Provision other than in the pharmacy consultation room

In agreement with NHSE&I regional teams, potential patients may be targeted and the service could be provided in other settings outside the pharmacy such as areas not designated part of the pharmacy within supermarkets or large stores or in community locations such as community centres, sports grounds and places of worship.

Patient advice

To further promote the service and support the provision of healthy lifestyle advice, contractors may consider the use of Public Health England (PHE) and other patient support or charity organisations such as the British Heart Foundation to source educational materials to promote healthy behaviours, signpost to other services, and improve understanding about blood pressure.

To download or order resources including leaflets, posters, guides and resource packs for campaigns from the Public Health England campaigns web pages the Pharmacy will need to register on the PHE website.

Register here

Below are links some examples resources which may be appropriate to the healthy lifestyle advice offered as part of this service:

Consent

Prior to provision of the service, verbal consent must be sought from the patient by the pharmacist. In seeking consent, contractors need to ensure that the patient is made aware that the following sharing of information will take place:

• The sharing of information between the pharmacy and the patient’s general practice to allow the recording of the blood pressure reading in their GP practice record;
• The sharing of information about the service with NHSE&I as part of service monitoring and evaluation; and
• The sharing of information about the service with the NHSBSA and NHSE&I as part of post-payment verification.

The General Pharmaceutical Council’s Guidance on Consent provides information on consent for pharmacists and their teams.

Clinic blood pressure check

The first stage of the service is the provision of a normal blood pressure check (clinic check) in line with NICE guidelines.

A visual guide that can be used to support pharmacists providing this stage of the service is included in the template consultation form and as a standalone reference source.

Download the clinic blood pressure guide (PDF)

ABPM provision

Where a patient is identified as having high blood pressure (140/90mmHg or higher, but lower than 180/120mmHg) prompt provision of ABPM will be dependent on the availability of an ABPM device. Should the patient decline ABPM through the pharmacy, they should be referred to their general practice or another appropriate local pathway.

A leaflet that can be used to provide patients, relatives or carers with information about ABPM and what is involved is available.

Download the ABPM patient leaflet (Microsoft Word)

Download the ABPM patient leaflet (PDF)

When providing ABPM, contractors may wish to ask the patient to complete an equipment loan agreement.

Download a template ABPM loan agreement (Microsoft Word)

During a consultation to fit an ABPM device and in line with the device’s instructions and the training provided:

• Reset the ABPM;
• Fit the ABPM to the patient;
• Explain the functioning of the ABPM device to the patient;
• Confirm that the patient understands that they need to stop any activity and rest when the cuff starts to inflate, and that the ABPM is set to take measurements every 30 minutes during waking hours and every 60 minutes during sleeping hours for 24 hours;
• Explain they must not get the ABPM wet therefore, baths and showers should be avoided during the 24-hour period; and
• Arrange a follow up appointment to discuss the readings and return the equipment.

Should a patient fail to attend a scheduled pharmacy appointment to be fitted with an ABPM device, the pharmacy team should make at least two attempts, on separate occasions, to contact the patient to rearrange the appointment. In the event of a failure to attend, the patient’s GP practice should be provided with the initial clinic blood pressure measurement and notified that the patient failed to attend to be fitted with the ABPM device.

Return of ABPM devices

When the patient attends the ABPM follow up appointment:

• Retrieve the patient’s consultation data from the ABPM device in accordance with the manufacturer’s instructions;
• Record the average daytime, night-time and 24-hour blood pressure readings in the consultation record; and
• Based on the average 24-hour reading, the pharmacist should follow the relevant guidance in the service specification on the next steps for the patient. All six readings (systolic and diastolic for day, night and 24-hour average) and the full ABPM report should be shared with the patient’s general practice.

Failure to attend after ABPM for discussion of readings and equipment return

Where a patient fails to attend a scheduled follow up appointment, the pharmacy team should make attempts to contact the patient to rearrange the appointment and return the equipment. If despite the pharmacy team making several attempts on separate occasions to contact the patient, the patient does not return to receive their ABPM results within five working days, the pharmacist should:

• contact the patient’s registered general practice, to provide the initial clinic blood pressure result and notify the practice of the service user’s failure to attend following ABPM; and
• Suspend provision of the Hypertension Case-Finding Service until the ABPM meter is retrieved or a replacement device is available.

Information for patients and referrals

Blood pressure readings

Blood pressure readings should be discussed with the patient and results should be provided in a format that best suits the patient. The patient may prefer to have their readings written on a printed leaflet, it may be completed electronically by the pharmacist and emailed to the patient or the patient may prefer to take a photo of their readings using their phone.

Download a patient leaflet to support provision of readings (Microsoft Word)

Download a patient leaflet to support provision of readings (PDF)

Healthy lifestyle advice

In line with the principle of Making Every Contact Count, the pharmacist should encourage the patient to discuss their lifestyle/behaviours and appropriate lifestyle advice should be provided where applicable. Local initiative and services that may assist the patient should be signposted.

Examples resources which may be appropriate to support the patient or raise awareness are detailed in the above patient advice section.

Contractors should record any advice provided and any sign posting in the clinical record. Where a patient is not registered with a GP practice, information should be provided to assist the patient to do this.

Communicating with GP practices

Contractors must ensure that the patient’s GP practice is notified of the blood pressure reading.

Details of when to make referral based on the blood pressure monitoring outcome are detailed in the service specification and the PSNC Briefing for the service.

Details of the required information to be sent to the patient’s GP practice based on the blood pressure reading are outlined in Appendix B of the service specification. This also specifies the frequency of communication and the recommended subject title.

Download a weekly summary template (Excel)

Download a weekly summary template (OpenDocument)

Download an urgent, same day referral letter/email template (Microsoft Word)

Download an urgent, same day referral letter/email template (PDF)

Download an appointment within three weeks referral letter/email template (Microsoft Word)

Download an appointment within three weeks referral letter/email template (PDF)

Record keeping and data management

When the service first launches, there will not have been time for pharmacy IT suppliers to develop functionality in their systems to support the creation of clinical records for the service. Contractors will therefore need to make their clinical records in another way prior to the development of IT systems.

Download a template clinical record form (Microsoft Word)

Download a template clinical record form (PDF)

Summary data on each service provision will need to be manually submitted to the MYS platform as part of the payment claim process (see the next section for further details).

In due course, once IT system suppliers have had time to develop their systems, clinical records should be recorded in such systems.

During 2021, NHSE&I and NHS Digital will work with IT system suppliers to develop functionality that allows certain data from the clinical record of each service provision to be extracted and submitted to the NHSBSA’s MYS system via an application programming interface (API).

The information to be submitted via the API will be published in an updated version of the service specification in due course. When submitted to the NHSBSA, this data will be used for post-payment verification and it will also be shared with NHSE&I to support evaluation of the service.

Clinical records of service provisions should be retained for an appropriate period, but for the purposes of post-payment verification, they should be kept for a minimum of two years after the service takes place. As pharmacy contractors are the data controller, it is for each contractor to determine what the appropriate length of time is, beyond two years that the clinical records are kept for. Decisions on this matter should be documented in the SOP and should be in line with Records Management Code of Practice for Health and Social Care.

The following fees have been agreed for the service:

• A set-up fee of £440;
• A fee for each clinic check of £15; and
• A fee for each ambulatory monitoring of £45.

In addition, the following incentive fees across Years 3, 4 and 5 of the CPCF 5-year agreement, will be available. Pharmacies must reach a threshold of ABPM activity to trigger the payment of the incentive fee.

• An incentive fee of £1,000 will be available if 5 ABPM intervention are provided in 2021/22;
• Followed by a payment of £400 in the subsequent years if the pharmacy reaches the thresholds for those years (15 ABPM interventions will be required in 2022/23 and 20 in 2023/24).

Contractors who sign up after Year 3 must achieve the ABPM activity thresholds specified for the given financial year and will receive £1,000 as a first payment. If a contractor signs up in Year 3 and fails to do 5 ABPMs, they can earn £1000 by doing 15 ABPMs in Year 4. These incentive payments will be funded separately (i.e. from outside the pharmacy global sum) by NHSE&I to incentivise case finding in line with the ambition outlined in the NHS Long Term Plan.

To achieve these targets, contractors will need to first identify people in whom ABPM is indicated, i.e. people with high clinic blood pressure measurements who then accept ABPM with accompanying support and advice.

The incentive fees will help contractors to fund the capital cost of purchasing a suitable clinic BP meter and an ABPM.

If clinic blood pressure measurements or ABPM are provided at the request of a general practice, the service fees set out above will be paid to the contractor.

If changes to the VAT rules can be agreed between DHSC, HM Revenue and Customs and HM Treasury, to ensure pharmaceutical services provided by non-pharmacists, but under pharmacist supervision are VAT exempt, the service will be modified to allow aspects to be provided by the wider pharmacy team and the fees will be amended to reflect the greater use of skill mix within the service.

Claiming

The interim dataset to be reported to NHSBSA’s MYS portal is listed in Appendix C of the service specification. Data should only be reported for the completed service. For example, where a clinic check has been undertaken and an ABPM is required, which will be undertaken in the following month, the data for the complete service provision should be reported once both elements of the service (clinic check and ABPM) have been completed.

Claims for payments for this service should be made monthly, via the NHSBSA’s MYS portal.

An application programming interface (API) will be available in due course within pharmacy IT systems which support the creation of clinical records for the service. This will support the required dataset being extracted from pharmacy IT systems with the data being submitted to the MYS portal. Details on the timing of the API introduction and the full dataset for the hypertension case-finding Advanced service will be made available in due course.

If the pharmacy contractor wishes to stop providing the hypertension case-finding advanced service, they must notify NHSE&I that they are no longer going to provide the service via the MYS platform, giving at least one months’ notice prior to the cessation of the service.

Visit the Hypertension Case-Finding Service Frequently Asked Questions page for FAQs on the service requirements.

Access the on-demand webinar 

NHSE&I case study: Rohpharm Pharmacy
As part of NHSE&I’s activity to support the International Society for Hypertension’s May Measurement Month campaign, which raises awareness of the risks of high blood pressure, they have published a case study on Rohpharm Pharmacy in Newham, East London who are providing the Hypertension case-finding service.

PSNC clinical service statistics dashboard
The dashboard presents data on the Hypertension case-finding service (as well as other Advanced services) at three levels (national, LPC and individual pharmacy) for each quarter. The dashboards are based on  the NHS Business Services Authority’s (NHSBSA) Dispensing Contractors’ data.

NHSBSA Dispensing Contractors’ data
Data on the Hypertension case-finding service (as well as other Advanced services) can be found by clicking on the ‘Pharmacy and appliance contractor dispensing data’ dropdown tab.

Chief Pharmaceutical Officer’s blog on hypertension awareness
In a blog published on 17th May 2022 to mark World Hypertension Day, NHS England and NHS Improvement has revealed that more than 6,800 community pharmacies have signed up to provide the service and over 75,051 checks have been carried out by community pharmacies.

Service pathway (PDF)

Slide deck for use by LPCs at local events (PowerPoint)

Slide deck for use by LPCs at local events (PDF)

Contractor implementation checklist (PDF)

Template clinical record form (Microsoft Word)

Template clinical record form (PDF)

GP letter / email service notification template  (Microsoft Word)

PSNC Briefing for general practice teams (PDF)

Practice referral template (Microsoft Word)

Practice referral template (PDF)

Service poster (PDF)

Service digital marketing resources (PDF)

Small flyers to use on prescription bags etc. (Microsoft Word)

Small flyers to use on prescription bags etc. (PDF)

Template patient leaflet to promote the service (Microsoft Word)

Patient leaflet to promote the service (PDF)

Pharmacy team Briefing (PDF)

Clinic blood pressure guide (PDF)

ABPM patient leaflet (Microsoft Word)

ABPM patient leaflet (PDF)

Template ABPM loan agreement (Microsoft Word)

Patient leaflet to support provision of readings (Microsoft Word)

Patient leaflet to support provision of readings (PDF)

Weekly summary template (Excel)

Weekly summary template (OpenDocument)

Urgent, same day referral letter/email template (Microsoft Word)

Urgent, same day referral letter/email template (PDF)

Appointment within three weeks referral letter/email template (Microsoft Word)

Appointment within three weeks referral letter/email template (PDF)

The following links provide further information on Hypertension and related topics.

• Blood Pressure UK
• British and Irish Hypertension Society
• British Heart Foundation
• NHS website
• NICE guideline [NG136] – Hypertension in adults: diagnosis and management
• NICE Clinical Knowledge Summaries

If having read the service specification and the information on this webpage pharmacy contractors have outstanding questions regarding the service, they can email them to services.team@psnc.org.uk.

LPC Resources

Slide deck for use by LPCs at local events (PowerPoint)

Slide deck for use by LPCs at local events (PDF)