Q. Why is community pharmacy not able to initiate home blood pressure monitoring as part of the service?
NICE guideline NG136 specifies that ambulatory blood pressure monitoring (ABPM) is the clinically preferred method for diagnosing hypertension. Home blood pressure monitoring is therefore only an acceptable alternative where the patient cannot tolerate ABPM and NHSE&I has decided that those patients should be referred to their general practice.

Q. Is atrial fibrillation detection part of the hypertension case-finding service specification?
No. Irregular pulses may be detected during the service, including by the BP meter if it has this functionality. However, detection of atrial fibrillation it is not a part of the service.

Q. Is every contractor expected to go live from 1st October 2021?
No. It is an Advanced service, so contractors are free to choose if they will provide the service and when they will start provision. At the time of launch, most contractors will be busy providing the flu vaccination service and subsequently winter-related workload is also likely to mean they may not immediately have time to implement the service.

Q. Is provision of the service mandatory?
No. This is an Advanced service, so contractors are free to choose if they wish to provide the service.

Q. Are there any resources available to support the engagement of general practice teams?
Yes. A GP practice Briefing is available on the PSNC Hypertension Case-Finding Service webpage.

Q. My pharmacy has an exemption from NHS England and NHS Improvement on the requirement to have a consultation room. Can I therefore provide the service from a designated area in the pharmacy or outside my pharmacy?
No. It is a requirement of the service specification for pharmacies to have a consultation room which meets the requirements in the Terms of Service to provide the service.

Q. Is there an IT system to support the service?
At the time of launch of the service, IT system providers have not had any advance notice to allow them to develop IT systems. Initially contractors will need to provide the service and maintain their clinical records on paper or using alternative IT options available to them. IT system suppliers will need time to develop solutions and an application programming interface (API) to facilitate transfer of data into the NHSBSA’s Manage Your Service (MYS) platform to support claims for payment.

Q. Will NHSE&I cover the cost of procurement of an appropriate IT system to provide the service?
Procurement of IT systems to support the service is the responsibility of the contractor and the cost of this has been recognised in the funding for the service.

Q. Can the pharmacy just provide clinic checks and not ABPMs?
No. The service requires that the pharmacy must be able to offer both stages of the service (clinic checks and ABPM).

Q. If a pharmacy does not have a consultation room, but has access to an appropriate room twice a week are they still ineligible for the service?
Yes. It is a requirement of the service specification for pharmacies to have a consultation room on the pharmacy premises which meets the requirements in the Terms of Service to provide the service.

Q. Are there any additional requirements to consider beyond those of the Terms of Service for our consultation room?
Yes, the consultation room should also comply with the following requirements:

• when measuring blood pressure, the patient must be able to rest their arm on a table / bench at a suitable height; and
• it must have IT equipment accessible within the consultation room to allow contemporaneous records of the consultations provided as part of this service to be made.

Q. Why can only pharmacists provide the service?
Under current VAT rules, pharmaceutical services provided by other staff under the supervision of a pharmacist attract VAT, which will not be reimbursed as part of the service fee. Therefore, to start with, the service will only be provided by pharmacists as the associated fees are exempt from VAT. If changes to the VAT rules can be agreed between the Department of Health and Social Care, 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.

Q. Can trainee pharmacists provide this service?
No. Currently only pharmacists can provide the service.

Q. We have a BP monitor described as recommended by NICE but it is not validated by the British and Irish Hypertension Society. Can we use this for the clinic service?
No. Blood pressure monitors used to provide the service must be validated by British and Irish Hypertension Society.

Q. Will any equipment be provided to support the service?
The responsibility of purchasing equipment to provide the service sits with the contractor.

Q. Is there any reimbursement for the purchase of the equipment as the set-up fee does not cover equipment costs?
The incentive fees that have been negotiated as part of the service are intended to help contractors to fund the capital cost of purchasing a suitable clinic BP meter and an ABPM. Pharmacies must reach a threshold of ABPM activity each year to trigger the payment of the incentive fee.

Q. Can PSNC recommend a shortlist of the appropriate equipment from the British and Irish Hypertension Society validated list, or provide further details on each of the listed equipment?
No. PSNC cannot recommend or influence the choice of equipment for provision of the service. Before a decision is made about the purchase or rental of equipment, there are several considerations that 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.

Q. Are there any recommendations to reduce the risk of the expense associated with having to replace lost or damaged devices?
Contractors are recommended to explore obtaining insurance for devices taken away from the pharmacy. This may be available via insurance providers or trade organisations.

Q. How often does calibration of the equipment need to occur?
The calibration of the monitors used to provide the service should be conducted in line with the manufacturer’s instructions.

Q. Do you recommend contractors have more than one ABPM device in the pharmacy?
Contractors will need to consider the best way to provide the service, which includes considering the need and availability of equipment necessary to provide the service. While the availability of more than one ABPM may prove practical for some contractors in the long term, the cost associated with the devices versus the income that can be generated by a contractor providing the service must be carefully considered before any such decisions are made.

Q. The service specification is endorsed as a ‘DRAFT’, can we use this service specification to initiate the service?
Yes. The final specification is making its way through the NHSE&I approval process, but the service can be started using the draft service specification.

Q. How do contractors sign up to provide the Hypertension Case-Finding Service?
Contractors can sign up to provide the service by completing a registration declaration on the NHS Business Services Authority’s (NHSBSA) Manage Your Service (MYS) portal.

Q. Are pregnant women aged 40 years or older eligible for the service?
People who have their blood pressure regularly monitored by a healthcare professional, such as pregnant women, would be excluded from the service unless monitoring is at the request of a GP practice. If the service is provided to pregnant women, then it must be provided in line with NICE guidance.

Q. Should there not be an upper age limit for the service because NICE guidance for people over 80 years of age allows prescribers to initiate treatment at slightly higher blood pressure levels than the bands identified in the service?
NICE guidance on diagnosis of hypertension covers all adults; no reference is made to age. Therefore, no upper age limit has been placed on the service. Guidance on the over 80s only comes into consideration in the NICE guidance when considering potential treatment or monitoring when diagnosed.

Q. Are individuals who may not be registered with a GP eligible for this service?
Yes. Where an individual is identified as suitable for the service, but is not registered with a general practice, the service can still be provided. The individual should be provided with their results and with information on how to register with a local practice. If escalation of their results is required, this should be undertaken via the locally agreed route, which may include referral to an emergency department if needed.

Q. Can we offer this service to people under 40 years of age at a patient‘s request or if the patient has a family history of hypertension?
Yes, at the pharmacist’s professional discretion. The inclusion criteria for the service provides, by exception, that people 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. People between 35 and 39 years old who are approached about or request the service may also be tested at the pharmacist’s discretion.

Q. Can I measure the blood pressure of my staff?
If pharmacy team members meet the requirements of the inclusion criteria for the service, then they can have their blood pressure measured as part of the service. Where pharmacy team members do not meet the requirements of the service, pharmacists can provide the service to pharmacy staff members as part of practising their consultation and service provision technique, but the contractor cannot claim remuneration for these provisions.

Q. If a patient’s practice requires the patient to monitor their blood pressure over a period of seven days, can we provide the clinic check part of the service to support the patient?
No, such checks are not within the scope of the service.

Q. If a patient had previously had a normal blood pressure measurement and NICE guidelines recommend that subsequent blood pressure measurements should only be done at least every five years, how would the pharmacy know if the patient’s general practice has done a blood pressure check in last five years?
The pharmacist providing the service could ask the patient about this or where the pharmacy has access to a local shared record system, this information may be available to the pharmacist within the system.

Q. What is the recommended retention period for the consultation records in this service?
No retention period has been specified for the consultation records, so it would be for the contractor to decide on retention periods. Two years meets the requirements for post payment verification; however a longer period may be required for clinical data records. This retention period is for the contractor to determine and should be in line with Records Management Code of Practice for Health and Social Care.

Q. Why is there no specific guidance for referrals from general practice to pharmacies?
There are no specific requirements set for referrals from general practice to allow contractors to work with general practices to agree a local process which will work for both parties. Different practices may require differ levels of support, so an open approach allows flexibility for contractors to support each practice as needed at a local level.

Q. My patient cannot tolerate or does not want to have an ABPM. Can I suggest home blood pressure monitoring?
Home blood pressure monitoring is only an acceptable alternative where the patient cannot tolerate ABPM and may be used for ongoing monitoring for those patients who have a prior diagnosis of hypertension. If the patient cannot tolerate ABPM, you should refer them to their GP practice.

Q. Can I provide the service off-site?
Yes, but only in agreement with your NHSE&I regional team. 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.

Q. Do I have to provide the patient’s GP practice with their readings if they are normal?
Yes. Contractors must ensure that the patient’s GP practice is notified of the blood pressure reading in all circumstances.

Q. May I charge a deposit for loan of the ABPM device?
Legal advice received by PSNC is that there is no statutory power which would permit contractors to charge a deposit for the loan of the ABPM equipment and, consequently, such charges would be contrary to section 1 of the NHS Act 2006.

Q. May I seek a voluntary deposit for loan of the ABPM equipment?
Legal advice received by PSNC is that there is no statutory power which would permit contractors to charge for any lost or damaged items and, consequently, such charges would be contrary to section 1 of the NHS Act 2006.

Q. May I charge for any lost or damaged ABPM equipment?
Legal advice received by PSNC is that any charge for lost or damaged ABPM equipment is unlikely to be enforceable, either because it would have no statutory basis and, consequently, would be contrary to the NHS Act 2006, or because the patient may not have the means to pay.

Q. How can I seek to ensure the ABPM equipment is returned promptly and in good working condition?
PSNC has prepared a template ABPM loan agreement which the patient may be asked to complete. This stresses the importance of prompt return of the equipment in good working order for the patient to receive their clinical results from the pharmacist, for use by other patients in need of assessment and because the equipment belongs to the pharmacy.

Q. What if I intend to charge a deposit or a seek a voluntary ‘deposit’?
If contractors choose to offer the service they must offer and loan the ABPM equipment (and provide the service as a whole) in accordance with the relevant NHS (Pharmaceutical and Local Pharmaceutical Service) Regulations 2013 and the service specification. Failure to do so may result in NHSE&I taking performance proceedings (e.g. a breach notice).

If contractors intend to charge a deposit or ask for a voluntary ‘deposit’ they are advised to seek their own legal advice and ultimately it is for the courts to decide these issues.

Q. Is there any recourse to be able to reclaim the costs of damaged or stolen ABPMs?
No, there is no facility in the service specification to reclaim the cost of damaged or stolen ABPM equipment from the NHS. Contractors are advised to explore options for insurance of equipment that leaves the premises.

Q. Is it necessary to check a patient’s blood pressure in both arms?
Yes, NICE guidelines advise that when considering a diagnosis of hypertension, a patient’s blood pressure should be measured in both arms.

Q. How does a pharmacy confirm the NHSmail address for a GP practice they do not usually communicate with?
Pharmacies can use the NHS Service Finder to look-up non-public email and non-public telephone numbers (where available) for general practices. Pharmacies should then confirm with the practice that the identified email address is a suitable as a secure email that they can be used to send notifications or referrals to.

Q. Does the ABPM results transcript need to be sent to the GP practice, or can we just communicate the results?
The transcript of ABPM information (the output data/report from the ABPM device) should be sent to the GP for every patient who has had ABPM with clear patient details so practice teams can match them to patients. The transcript should be sent along with all six ABPM readings (systolic and diastolic for day, night and 24-hour average).

Q. Has communication taken place with general practice to make them aware community pharmacy will be making and sending requests for appointments for patients?
Yes. NHSE&I have engaged general practice about the service requirements and worked with the General Practitioners Committee (GPC) of the BMA to ensure there was input into the design of the service. NHSE&I will do further work with general practice to raise awareness of the service once community pharmacy has had an opportunity to consider and take up the service. PSNC has also discussed the service with the GPC and resources to help brief GPs have been issued for use by contractors.

Q. There is some local concern, from GPs, that the urgency associated with some of the referrals is unnecessary and that an appointment within one week would be more appropriate with a higher threshold for same day appointments. How do we address these concerns?
NHSE&I worked through the service with their national clinical advisor for cardiovascular disease, their national advisor for hypertension prevention and an expert group, which included representation from GPC, to consider and draw up the service requirements. The national service needs to provide consistency, however it is worded to allow some local ability to adapt. The service is designed to work at a primary care network (PCN) level. Therefore, if the PCN indicates that they want the escalation for patients identified as having very high blood pressure directed to an alternative route, e.g. an urgent treatment centre, then the service can be locally adapted in that way. That is one of the key reasons for contractors to initiate local conversations with general practice about the service.

Q. Can general practice refer women who require a blood pressure check so they can obtain their contraceptive pill?
Yes. While the focus of the service is case-finding in people aged 40 years and older, general practice can choose to refer any patients that require a blood pressure check to the pharmacy for support.

Q. Can referral from general practice for blood pressure checks be for any age?
Yes.

Q. If general practice refers a patient for a blood pressure check, do we have to provide both stages of the service?
Where a patient is referred from general practice for a blood pressure check, then contractors should provide a clinic blood pressure check. The provision of ABPM would then only be required where it is clinically indicated because of a high clinic blood pressure.

If the referral is specifically for an ABPM, then a clinic blood pressure check is not required as this will have been conducted at the practice. Contractors should only claim for the service stages they have provided.

Q. Can referrals to the service be made from secondary/tertiary acute trusts for pre and post treatment monitoring?
No. The service specification only allows referrals from general practices.

Q. Do the referral templates work both ways?
There are separate referral templates for contractors to use to notify and refer patients to their general practice and for general practice to use to refer patients to community pharmacies for a blood pressure check.

Q. When making a referral to a general practice, is the patient required to make the request for an appointment or is the pharmacy?
Where a patient has been identified with stage 1 hypertension following ABPM, or a low blood pressure with symptoms (dizziness, nausea or fatigue) then they are advised to make an appointment at their general practice within three weeks. The pharmacy is required to send a notification to the general practice on the same day to notify the practice of the results and the advice they have provided to the patient to make an appointment in three weeks.

Where a patient has been identified with a very high clinic blood pressure, a blood pressure indicating stage 2 hypertension following ABPM, an irregular pulse, or a low blood pressure that is putting the patient at risk or where the patient is experiencing regular fainting or falls, or feels like they may faint on a daily/near daily basis, then in these cases the contractor should contact the practice to attempt to make an urgent same day appointment for the patient to see their practice and then send the referral and notification of results the same day.

Q. If a patient does not return to be fitted for ABPM or does not return with the ABPM to obtain their results, does the initial consent still cover sharing the clinic results with their general practice?
Yes.

Q. If a patient refuses to have ABPM, what should we do?
Where a patient indicates, they do not want to have ABPM, they should be asked to make an appointment with their general practice within three weeks. The pharmacist should ensure the clinic blood pressure reading and the notification of referral are sent to the practice the same day.

Q. Will practices accept the pharmacy ABPM readings or will the patient be expected to undergo another ABPM?
Provided the pharmacy is able to provide the full ABPM transcript, there should not normally be a reason for the results to need to be repeated by the practice. If, as part of their assessment of the patient, the practice team identify other underlying causes of the blood pressure, then a repeat of the measurement may be required at a later time.

Q. Is there a time frame for a patient coming back for a repeat of the service?
NICE guidelines recommend that patients who have a normal blood pressure have a subsequent check in five years. Patients whose blood pressure is borderline normal or who have low blood pressure should have their next blood pressure check in a years’ time.

Q. If your ABPM machine is out with a patient and you find another patient with high blood pressure that requires ABPM, how long should you reasonably wait to offer ABPM?
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. Contractors should look to provide ABPM the same day where a device is available. Where a device is not currently available, as it is with another patient, ABPM should be offered as soon as the ABPM device will be available and is convenient to the patient.

Q. What does the set-up fee cover?
The set-up fee covers costs including creating an SOP for the service and training staff who will be involved in providing the service.

Q. If a patient has a normal blood pressure when the clinic check is provided, are we still paid?
Yes. Any provision of clinic blood pressure measurement where the patient meets the requirements of the inclusion criteria will be eligible for payment.

Q. If a patient does not return to have the ABPM fitted, can we still claim for the clinic blood pressure?
Yes, provided the patient’s general practice is sent the patient’s clinic blood pressure results.

Q. If a patient does not complete the 24-hour ABPM check for any reason (the machine reported an error, or the patient could not tolerate the device) and the customer declines another check, can we still claim for the service?
Yes. If the patient was fitted with the ABPM device and its use and functioning explained, where the patient subsequently does not complete the 24-hour monitoring and does not wish to try again,  then a service fee for ABPM can still be claimed for provision of the service. The service claim will need to include a flag to confirm the service was incomplete.

Q. Is there any limit on how many blood pressure checks can be conducted in line with the service specification and claimed for?
No.

Q. Could the £1000 incentive payment not be provided as funding upfront to support equipment costs to set up the service and claimed back if pharmacies do not reach the target for ABPM in year 4?
No. Several options were explored as part of Year-3 CPCF negotiations. The incentive scheme was the only option that could be agreed to provide contractors with a way to fund the capital costs associated with the equipment while meeting the NHS’ need to demonstrate service delivery.

Q. How often should claims be made for the service?
Claims must be made monthly and by the 5th of the month following completion of the service.

Q. If a GP refers patients for ABPM to the pharmacy, does provision of the service count towards the incentive payment targets?
Yes.

Q. Can we temporarily switch off the service if we need to due to heavy workload, e.g. holiday times, flu season?
While the pharmacy contractor must seek to ensure the service is available throughout the pharmacy’s core and supplementary opening hours, where a contractor needs to temporarily suspend the service, they will need to update their service availability on the service profile of the NHS website. They should also inform their GP practices of the temporary suspension and provide some indication of when the service will recommence.

Q. How do I withdraw from provision of the service?
Contractors can withdraw from the service by providing one month’s notice and completing the Hypertension Case-Finding Service withdrawn from service form on the MYS application.