As the demand for hospital and GP appointments continue to outstrip capacity, more patients than ever are waiting for treatment.
To help clear some of this backlog, community pharmacies all around the country are stepping up to expand their role in the prevention and management of cardiovascular diseases (CVD) – one of the major causes of death in the UK.
There are around 7.6 million people living with a heart or circulatory disease in the UK; 4 million men and 3.6 million women, according to the British Heart Foundation (BHF).
BHF funded research also shows that CVD disproportionality impacts people from Black African, African Caribbean and South Asian backgrounds – they are at higher risk of developing high blood pressure or type 2 diabetes compared with White Europeans.
As community pharmacies are disproportionately located in deprived areas, any services they provide will help address the widening health inequalities, something which the NHS Long Term Plan focuses on, alongside the prevention of ill health. It aims to prevent 150,000 strokes and heart attacks as a result of CVD, over the next ten years.
Many pharmacies have started providing the NHS Community Pharmacy Blood Pressure Check Service which supports risk identification and prevention of cardiovascular disease.
Catching patients early is key
Jignesh Patel, pharmacist and owner of Rohpharm Pharmacy in East London has been offering the NHS Community Pharmacy Blood Pressure Check Service as part of a NHS England pilot, which began in early 2020, before it became a national service in October 2021.
Now around 6,000 pharmacies are providing the service as a result of the success Jignesh had in the pilot stage.
“Services like these are extremely important,” Jignesh told InPharmacy.
“If it’s done well, it can help identify a lot more people with a higher risk of cardiovascular disease, much earlier.”
“For this disease, we’re targeting a young group, anyone over 40. We’re starting to get people aware of this before they even start thinking about it. It prevents them from going to the GP at the age of 50 and then finding out they have high blood pressure.”
The demographic of services users at Rohpharm pharmacy are largely mixed, with many coming from a South Asian background. Jignesh says he and his diverse, multilingual team, make sure they raise awareness of the service to everyone who is eligible.
“Newham, where we are based, is one of top five deprived areas in the UK with a very cosmopolitan population. We have a large mix of people Bangladeshi and Afro Caribbean origin and recently we’ve had an influx of Eastern European and Chinese people.
“All my staff talk to every customer that comes in about this service. They have developed confidence in engaging people, promoting the service and signposting them to local support. As part of their training, we brought everyone together to practise talking about what the pilot is all about and its benefits, what it means for health and why a referral might be made. Each team member now understands the process and how long it takes and can answer people’s questions about healthy living.”
Using a family orientated approach and by speaking to people in their own language, the pharmacy has generated high numbers of people willing to have a blood pressure check who may not otherwise have thought to attend.
Jignesh said: “We have a diverse group of staff members who can speak Spanish, Portuguese, Gujarati and Bengali. Speaking to people in their own language actually helps to educate them about blood pressure and even lifestyle choices. It goes a long way in preventing long term diseases.”
Rohpharm Pharmacy has done 220 clinical blood pressure checks since starting the service and out of those, they’ve had 58 ambulatory blood pressure monitoring (ABPM) tests done. Up to 20 per cent of these patients were eventually diagnosed with hypertension.
“It’s part of the contract - if you identify someone with high blood pressure you have monitor them for 24 hours via the ABPM, unless the patient declines. Once that is done we make a decision based on what the results are and whether we have to refer them on for further assessment or whether it’s better they get lifestyle advice instead, making them more aware of the condition.
“And the patients diagnosed with hypertension are referred back to us again, to do a New Medicine Service, so we can make sure they stay on their medication.”
Under the contract, Jignesh explained that pharmacies have the opportunity to do the hypertension service outside the pharmacy premises too.
“We can go to places like shopping centres or mosques to do this. The only drawback is that there’s no additional funding to pay for the cost of a locum to look after the pharmacy, while the pharmacist goes into these places. It would be a brilliant way to catch a lot of people.”
Jignesh added: “Throughout the year there are peak seasons for different groups of people to target so if there’s appropriate remuneration for pharmacists to be released and to go out into the community, we could help so many people.”
Training to better treat CVD
In order to better help patients with CVD some pharmacists are training to become independent prescribers (IP) so they can prescribe medicine to patients help prevent and manage their CVD.
Afua Thompson a pharmacist from Sutton who runs H.E. Matthews Pharmacy, is currently doing an IP course on hypertension.
She has been running an anti-coagulation clinic for over eight years after her CCG approached her with the request.
“We had patients who weren’t being managed very well so we were asked to take over,” she told InPharmacy.
“We took patients from hospital, GP surgeries and other pharmacies who struggled to maintain the service.”
H.E. Mathews Pharmacy currently manages 400 patients who are a mix of ambulatory patients and domiciliary patients. Afua and her team monitor and dose patients with atrial fibrillation (an irregular heart beat) and heart valves who are on Warfarin.
“We do a blood test which is a finger prick and dose them straight away so they know what they’re on. If their reading is too high, it’s important we bring it down straight away by dosing them – that way, they’re at less risk of bleeding and going to A&E.”
Afua said her CEPIP (Clinically Enhanced Pharmacist Independent Prescribing) course fits in nicely with her current work of managing patients with atrial fibrillation and heart valves.
“I’m already doing warfarin, which I’m confident in, but with hypertension I thought there’s a need for it because it can easily be captured in a pharmacy. Also the hypertension case finding service is already being rolled out in pharmacies so it makes sense. Hypertension is a silent disease, people are walking around not realising they’ve got high blood pressure
“We hear of cases where people who appear to be normal have just had a stroke or died and we find out later there was an underlying case of hypertension which could have been spotted sooner. Being able to prescribe for such patients in community pharmacy would be amazing because that is something that could easily be done.”
Afua believes the ease of access and advice that pharmacies provide make them an ideal place for educating the public on CVD.
“The black, Asian and ethnic minority communities for example are more prone to these conditions due to their lifestyle, eating habits and low socio economic status. It’s only through education we can get this done and community pharmacies are the best to do this as they’re the first port of call. Patients find it so easy to just walk in.”
Afua said that around 20 per cent of our patients are from black and Asian communities and she explains that they often keep things like hypertension to themselves.
“I remember in Ghana some people used to say ‘don’t take your blood pressure medication otherwise it’s going to become part of your life forever’. We still have those beliefs and carry them over to this country. We should be taking the medication to prevent other health risks and be aware of what could happen if we don’t take it.”
Piloting an AF check service
Another pharmacy group also helping to prevent CVD related issues in its community is the O’Brien’s Pharmacies Group based in North West England. They are offering a free Atrial Fibrillation (AF) check to over 65s in the region.
The service is a pilot for six months as a collaborative working agreement between Daiichii Sankyo and O'Brien's Pharmacy group. O'Briens pharmacy are directly recruiting and referring patients for the project across all nine of its branches. The project went live with its first patient in March 2022.
Lisa Cottam, Area Manager and Superintendent Pharmacist at O'Briens Pharmacy Group told InPharmacy that around 400 people have been screened so far.
"The aim of the project is to support the five year contractual framework for community pharmacy focusing on detection and prevention of cardiovascular disease,” explained Lisa.
“Pharmacies are often used as a point of treatment rather than a point of prevention so initiatives like these help to prevent major cardiovascular incidents which obviously cost a lot more money to treat in the long run.”
In the coastal town of Fleetwood, where the majority of O’Briens’ AF screenings take place, there is a much lower life expectancy compared to the rest of the UK said Lisa.
“Even though we do have pretty good access to healthcare, prevention of disease is key in trying to increase life expectancy and to ensure people are being referred in as soon as possible, rather than waiting for appointments.”
One way that Lisa and her team have been trying to capture more people for the service is by attending community and awareness events.
“One of staff members went out recently as part of a local health project, part of the Healthier Fleetwood initiative called Time for Tea, where she demonstrated the AF screening service. The feedback she had was very positive - once someone has a go, everybody wants to have a go.
"I would love to see an AF service commissioned locally. The service we're offering is non evasive and it takes a minute for the screening. It is something portable and we can take it out into the community; so far it's been very well received by patients.
“Long term, we'd like to reduce hospitalisations related to stroke and ultimately it’s raising awareness of cardiovascular disease in the community, how to prevent it and the risk factors.”
NPA guidance on CVD
The National Pharmacy Association (NPA) has created practical guidance for its members on carrying out a hypertension service in a pharmacy.
Jasmine Shah, Head of Advice and Support Services at the association, said hypertension is one of the biggest risk factors for heart failure, stroke, chronic kidney disease, dementia and premature death.
“There are millions of people in the UK who are unaware they have the condition, and are at risk of potentially developing serious health conditions,” she says.
“The good news is it is possible to monitor and treat, with diet and exercise and prescription medicines. Hypertension management absorbs about 12 per cent of all GP appointments and costs the NHS £2bn. Community pharmacists are skilled clinicians who could do far more to manage long-term conditions and ease NHS pressures, with the right support.”
Resources to support NPA members with service provision, including a template SOP for the hypertension case-finding Advanced Service can be found here: https://www.npa.co.uk/services/hypertension-case-finding-advanced-service/