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A project by: Focus on... High Blood Pressure (HBP) September 2014 High blood pressure (HBP), also known as hypertension, is one of the main, preventable causes of illness and premature death in the UK. HBP is usually defined as 140/90 mmHg or above. However, the level of blood pressure at which treatment is given varies depending on whether there are other risk factors affecting a particular patient. HBP is an integral factor in the development of stroke, chronic kidney disease (CKD) and cardiovascular disease (CVD), a group of diseases of the heart and blood vessels. HBP is by far the most common long-term condition in Islington, affecting 14,830 adults under the age of 75. HBP disproportionately affects people from poorer backgrounds and BME (Black and Minority Ethnic) groups as HBP risk factors are more prevalent in these communities, leading to health inequalities in the borough. Key facts and figures 1 in 4 Islington adult residents have high blood pressure 2012 32% 20,230 of people with high blood pressure are from black and minority ethnic groups adults in Islington have diagnosed high blood pressure 2012 2012 1% 11% 77% of people with a long term condition have never had their blood pressure measured 2012 of people with high blood pressure also have coronary heart disease, which is the main cause of death in Islington 2012 of people with uncontrolled high blood pressure are not on any anti-hypertensive medication 2012 Key programmes and services Programmes focus on the early identification and management of high blood pressure, and interventions to reduce risk factors such as smoking, poor diet and lack of exercise. The NHS Health Checks programme aims to diagnose disease and manage cardiovascular disease and its risk factors, including high blood pressure Primary prevention programmes to reduce the risk factors for high blood pressure, such as Stop Smoking services, weight management services and exercise referral programmes Closing the Prevalence Gap is a locally commissioned service aiming to reduce the gap between diagnosed and undiagnosed long-term conditions, including high blood pressure. Key measures for reducing inequalities The ‘wider determinants of health’ are the social, economic and environmental conditions which influence the health of individuals and populations. Building upon the existing work of Islington Councils, Islington CCG and other partners, the recent transition of Public Health into local government provides an opportunity to consider what more can be done locally to reduce health inequalities by tackling the wider determinants of health. Alongside a focus on influencing the determinants of health, we are working to better target our services aimed at preventing and managing long term conditions. To reduce health inequalities we work to improve access and increase uptake for people in different age, ethnic, geographical and gender groups who may be missing out. evidencehub.islington.gov.uk Key population groups The risk of developing high blood pressure increases as people get older. People from Black African or Caribbean backgrounds, and those with a family history of high blood pressure, are also at an increased risk. ‘At risk’ groups People aged 65 + People from African or Caribbean ethnic groups People with a family history of high blood pressure What are the risk factors for high blood pressure? In most cases, the specific cause of high blood pressure is unknown, but various factors can increase the risk of developing the condition: age (the risk increases as you get older), a family history of high blood pressure (the condition seems to run in families), being of Black African or Caribbean origin, a diet high in salt, lack of exercise, being overweight, smoking, and drinking alcohol above safe drinking levels. About 10% of high blood pressure cases are the result of an underlying medical condition. These cases are called ‘secondary high blood pressure’. Common causes are kidney disease and diabetes. High blood pressure can also be caused by some hormonal problems. Age People over 65 years of age have a 90% chance of developing high blood pressure by the time they reach 80. Smoking People who smoke are at a higher risk of developing high blood pressure. Smoking damages the lining of the arteries, meaning there is more resistance to blood flow, increasing the pressure in the arteries. Diet Having a diet high in salt is a key risk factor for high blood pressure, as are the consumption of alcohol and caffeine based drinks, including coffee. Physical inactivity A lack of physical activity, and in particular inadequate levels of aerobic activity, are linked to higher incidence of high blood pressure. Obesity Being overweight or obese increases the risk of having high blood pressure. Clinical Risk Factors High blood pressure is particularly common in people with kidney disease. The kidneys play an important role in controlling blood pressure. High blood pressure is more common in people with diabetes. Around 3 in 10 people with Type 1 diabetes and around 8 in 10 people with Type 2 diabetes develop high blood pressure at some stage. evidencehub.islington.gov.uk THE ISLINGTON PICTURE We gather information from GPs and from patient surveys to plan our services and provisions. This enables us to get the right treatment to the right people. Disease modelling suggests that many people with high blood pressure, do not know that they have it. This is not surprising as there are usually no symptoms. It is however important to diagnose high blood pressure early so that people can access treatment sooner, reducing the impact of HBP on their long-term health. Diagnosed prevalence Expected prevalence 20,800 25,900 10.8% 24.2% Numbers diagnosed Estimated numbers undiagnosed Who has high blood pressure? High blood pressure prevalence by age and sex, 2012 higher rate of HBP in the most deprived areas of Islington than the least deprived areas 2012 Men 80% Women 70% 60% 50% 40% 30% Most Least deprived deprived Islington average 90% Deprivation quintile Percentage of people 100% 17% 20% 10% 0 50 100 Indirectly standardised ratio 0% <40 40-59 60-79 32% 80+ Age group 150 of people with diabetes are from BME groups. This is significantly higher than the percentage of BME people in the Islington population (28%) 2012 What other long-term conditions do people with high blood pressure have? HBP & HBP & 3 LTCs 4+ LTCs 7% 4% HBP only 42% 0% 20% HBP &1 LTC 31% 40% 60% 20,233 people diagnosed with high blood pressure HBP &2 LTCs 15% 80% Diabetes Mental 5,243 Health 26% 3,408 17% 100% Percentage of people 58% of people diagnosed with HBP, also have at least one other diagnosed long-term condition (LTC). 15% of people have two LTCs, and 7% are living with three or more diagnosed LTCs 2012 Source: Islington GP Public Health dataset, 2012 CKD 2,656 13% CHD 2,187 11% 26% of people diagnosed with high blood pressure also have a diagnosis of diabetes 2012 evidencehub.islington.gov.uk Prevalence Expected and recorded prevalence of high blood pressure, by GP practice, in Islington's registered population aged 16+ 2011/2012 Diagnosed prevalence of high blood pressure varies by GP Practice, from 7% to 20%. 50% 45% Prevalence 40% 35% In all GP practices in Islington, diagnosed prevalence of high blood pressure is significantly lower than expected prevalence. 30% 25% 20% 15% 10% 5% I New North Health Centre The Family Practice Barnsbury Medical Practice Roman Way Medical Centre Bingfield Street Surgery Pine Street Medical Practice Dartmouth Park Practice The Rise Group Practice Dr Moneeb's Surgery Andover Medical Centre St John's Way Medical Centre Elizabeth Avenue Group Practice GP practice Expected prevalence Recorded prevalence significantly lower than expected prevalence Partnership Primary Care Centre The Medical Centre Goodinge Group Practice Mitchison Road Surgery Archway Primary Care Team The Miller Practice Sobell Medical Centre Dr Kateb & Partner Mildmay Medical Centre River Place Group Practice The Village Practice The Northern Medical Centre City Road Group Practice Hanley Primary Care Centre Amwell Group Practice St Peter's Street Medical Practice Ritchie Street Group Practice Holloway Medical Clinic Highbury Grange Medical Centre Stroud Green Medical Clinic Dr Ko's Surgery Killick Street Health Centre Clerkenwell Medical Practice Islington Central Medical Centre 0% Note: Wedmore Gardens Surgery is not included in the ERPHO modelled estimates of prevalence owing to its small list size, therefore this is not displayed on the graph. Source: Islington GP Public health dataset, 2012 Islington expected prevalence (24.3%) Islington recorded prevalence (10.6%) 95% Confidence Intervals Management Diagnosing people with high blood pressure allows for appropriate treatment and interventions to be given. People with a long term condition may be at increased risk of high blood pressure, and should have their blood pressure measured regularly. Blood pressure recording in people with: No long term conditions 33,574 22% At least one long term condition 55,372 37% In the past 15 month 485 6,266 1% 16% Not in the past 15 months Never recorded 62,317 41% 31,402 82% In the past 15 months Not in the past 15 months Never recorded One way of managing uncontrolled high blood pressure is through anti-hypertensive medication. However, 77% of people with uncontrolled high blood pressure have not been prescribed anti-hypertensives. Percentage of people with uncontrolled high blood pressure Percentage of people with uncontrolled high blood pressure prescribed anti-hypertensives 1,907 23% 8,356 41% 11,877 59% Not prescribed antihypertensive medication Uncontrolled Controlled Source: Islington GP Public Health dataset, 2012 evidencehub.islington.gov.uk 6,367 77% Prescribed antihypertensive medication Note: data on medications is not comparable to the previous HBP factsheet (Oct 2012) WHAT DO LOCAL PEOPLE THINK ABOUT THE ISSUE? It is important to understand peoples’ views and experiences of high blood pressure, in order to prevent and manage the condition effectively. Healthwatch Islington carried out a survey of some of the Islington residents who have a long-term condition. From this research they identified that people with long-term conditions really value peer support as well as being able to access reliable information regarding their own condition. Respondents interviewed were keen to be able to self-manage their condition where possible but also identified the need to be able to easily access health professionals during times of need. WHAT WORKS? High blood pressure is largely managed in primary care. Early identification of high blood pressure and management with anti-hypertensive treatment has been shown to be effective in managing HBP. Trials of anti-hypertensive treatment have also confirmed a significant reduction in the incidence of stroke and coronary heart disease in patients with high blood pressure. Primary prevention Interventions to reduce the prevalence of risk factors in the general population, including smoking cessation, increasing physical activity and healthy eating, and particularly reducing salt intake. Case finding and early diagnosis Identification and assessment of patients with high blood pressure, for example through the NHS Health Checks Programme and management of key risk factors through appropriate advice on smoking, diet, and physical activity. Management and control Management of high blood pressure in primary care to prevent the development of cardiovascular disease, for example heart attacks and strokes. Management includes supporting people to make the necessary lifestyle changes, such as stopping smoking, having a healthy diet and exercising more. Management also includes pharmacological treatment with antihypertensive drugs. Future need Estimated projections of high blood pressure prevalence are not available. The estimated prevalence of high blood pressure each year has remained relatively static and therefore the proportion of people living with high blood pressure is not expected to increase significantly. However population projections for Islington suggest an increase in the population over time, which we can expect to lead to the number of people living with high blood pressure to increase. evidencehub.islington.gov.uk Targets and outcomes There is a national target for the delivery of the NHS Health Checks programme. There are also a number of targets relating to high blood pressure (hypertension) in the Quality Outcomes Framework (QOF) which monitor performance of general practice. Document or strategy that target is taken from Target Deadline for target To offer an NHS Health Check to 20% of the eligible population every year NHS Health Check programme standards: a framework for quality improvement, 2014 April 2015 There are Quality Outcomes Framework indicators for hypertension, including: The Quality and Outcomes Framework April 2015 Establishing and maintaining a register of patients with diagnosed hypertension The percentage of patients with hypertension, in whom the last blood pressure (measured within nine months) is 150/90 or less. Target: 45-80% National and local strategies High blood pressure, as the leading risk factor for cardiovascular disease and CVD mortality, is a local and national priority. Actions to identify high blood pressure earlier and offer timely treatment are included in key national and local strategies and programmes. National Strategies Local Strategies National Service Framework for CHD, 2000-2012 Health and Wellbeing Strategy, 2013-2016 The National Service Framework for Coronary Heart Disease (NSF CHD), published in March 2000, set out to reduce CHD and stroke related deaths by 40% over 10 years. This target was met in five years. The framework identifies the treatments proven to be the most clinically effective & represent the best value for money. The framework also seeks to promote the integration of care for patients. One of three key priorities identified by Islington’s Joint Health and Wellbeing strategy is to improve the case finding and management of long-term conditions, including high blood pressure. NHS Health Check Programme The strategy includes recommendations to reduce the gap between recorded and expected prevalence for CHD, as well as recommendations to tackle the major risk factors of cardiovascular disease; high blood pressure, high cholesterol, deprivation and lifestyle factors such as smoking, poor diet and a lack of physical activity. The NHS health check programme is a national cardiovascular screening programme which aims to prevent coronary heart disease, diabetes and chronic kidney disease. It includes finding people with undiagnosed high blood pressure, so that the condition can be treated. Closing the Gap: Tackling Health Inequalities in Islington, 2010-2030 Islington’s Health Inequalities Strategy highlights the need for action to reduce early deaths due to CHD. The national programme targets health checks to eligible patients aged 40-74 once every five years. Islington Public Health is responsible for the local implementation of the programme and due to need offers a check to anyone aged 35-74. evidencehub.islington.gov.uk What is being done locally to address the issue? Primary Prevention There are a number of services in Islington are in place to improve lifestyle and health behaviours and help prevent long term conditions including hypertension. These include: Stop Smoking Services. These are available in many GP practices, pharmacies and community locations and are available to anyone living or working in Islington who smokes. Weight Management Services for people aged 18+ with a body mass index (BMI) >30 (>27.5 South Asian). Exercise on Referral services for individuals at high risk of CVD or diabetes or those diagnosed with a long-term condition. Alcohol Screening & Advice is available to all residents via primary care providers and dontbottleitup.org.uk an alcohol self-help website provided by Islington Public Health. Structured expert support is also available from Islington Community Alcohol Service. Broad programmes of work in collaboration with multiple stakeholders to encourage increased levels of physical activity and healthy eating in the general population. Identification and treatment of high blood pressure in primary care NHS Health Checks programme: This locally commissioned service is designed to case find and prevent heart disease, stroke, diabetes and kidney disease by identifying and treating people at high risk through targeting 35-74 year olds. During the Health Check individuals are also offered lifestyle advice. Between 1st April 2013 and 1st June 2014 39,319 checks have been delivered in Islington in general practices, pharmacies and outreach community centres. Health Checks have been proved to be effective for case-finding of CHD in Islington; between April 2011 and March 2012 51 new diagnoses of CHD and Myocardial Infarction (MI) were made following a health check. Closing the prevalence gap: The aim of this locally commissioned service is to reduce the gap between diagnosed and undiagnosed prevalence of a number of long-term conditions including high blood pressure. GP practices proactively identify those people on their practice register who have had a raised blood pressure reading but have not had any follow-up thereafter. Identified individuals are then followed up, managed in primary care and referred into lifestyle services as appropriate. evidencehub.islington.gov.uk Further information Further information on this topic can be found at the following locations Blood Pressure Association, 0207 882 6218 www.bloodpressureuk.org British Heart Foundation, 0300 330 3311 www.bhf.org.uk The Stroke Association, 0303 3033 100 www.stroke.org.uk Hypertension. Clinical management of primary hypertension in adults. NICE, 2013 http://guidance.nice.org.uk/CG127/NICEGuidance The NHS Health Checks Programme http://www.healthcheck.nhs.uk/ NHS Islington (2011) Annual Public Health Report 2011: Extending Life in Islington http://www.islington.gov.uk/publicrecords/library/Public-health/Quality-and-performance/Reporting/2012 -2013/(2013-01-18)-APHR-2011-Full-report.pdf Coronary Heart Disease: national service framework for coronary heart disease—modern standards and service models. Department of Health, 2000. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4094275 NHS Islington/Islington Council (2010) Closing the Gap. Tackling Health Inequalities in Islington 20102030 http://www.islington.gov.uk/publicrecords/library/Democracy/Quality-and-performance/ Reporting/2011-2012/(2012-03-03)-NHS-Islington.pdf Contact information: Weight Management: www.aquaterra.org/activities/aquaterra-rebalance-weight-management Alcohol Screening & Advice: www.dontbottleitup.org.uk or call 0808 800 0019 Stop Smoking Services: www.smokefreeislington.nhs.uk/ or call 0800 093 9030 About the Evidence Hub The Evidence Hub is a partnership between the local NHS and Islington Council that brings together information held across different organisations into one accessible place. It provides access to evidence, intelligence and data on the current and anticipated needs of the Islington population and is designed to be used by a broad range of audiences including practitioners, researchers, commissioners, policy makers, Councillors, students and the general public. This profile has been produced by Polly Reynolds, Assistant Public Health Strategist and signed off by Liz Brutus, Assistant Director of Public Health. For more information contact [email protected] or call 020 7527 8086. © Islington Public Health evidencehub.islington.gov.uk