Dr John Allingham offers some advice on how to maximise coverage and minimise costs when running a blood pressure monitoring local enhanced service
Current NICE guidance allows for hypertension to be diagnosed by taking the patient’s mean daytime blood pressure.
The gold standard is to use 24-hr ambulatory blood pressure monitoring (ABPM).
However, NICE also allows for readings to be taken morning and evening for a week. The first day is discarded and the mean of the next 12 readings taken as the daytime mean. Some enhanced service specifications will allow for this alternative technique in some circumstances.
It is crucial to read the contract specification carefully and comply with the requirements.
Here are some tips to help you run the service effectively and profitably.
Many practices can only perform four tests per machine per week, as the ABPM machines cannot be fitted on a Friday morning to be removed on a Saturday.
If the practice or Primary Care Network (PCN) has extended hours clinics on a Saturday morning this allows for a patient to be fitted on Friday morning and another on Saturday morning. The latter will need to remove the machine themselves on Sunday morning. With careful co-ordination, a Saturday morning service will allow for one 24-hour ABPM machine to be used six times per week instead of four.
Machines are subject to wear and tear, or even damage. Although they are expensive it is worth considering having a spare, so the service is never suspended for technical reasons.
Encourage all staff to opportunistically check blood pressure; measurement of any adult patient who has not had a check for 3 years is good practice, helps the QOF prevalence figures and will generate business for this service.
The practice could run a friendly incentive scheme where the member of the team who performs the most relevant opportunistic tests receives a small reward – for example, cinema tickets or a meal out.
Testing the target group is important. It is worth having a self-measuring machine in the waiting room and making personal contact with all patients having borderline or raised readings to offer the service.
Avoiding ‘did not attends’ (DNAs) is crucial. 24-hour ABPM machines are too expensive to leave idle. Sending text message reminders or ringing patients the day before their appointments helps.
It is also worth having a few flexible patients on the standby list to come in for late cancellations. This may be best achieved across a PCN footprint or by practices collaborating.
Many patients will be working so it is worth offering an early morning service. Could a healthcare assistant (HCA) be available at 07.30? Alternatively, the machine can be fitted in the evening – although be mindful that the machine disturbs sleep so patients may remove it at night.
Ensuring the service is run by staff working at the top of their licence is crucial. In most cases this service can be delivered by suitably trained HCAs.
Downloading and creating the reports for GP interpretation can be time consuming. Try to get this done by the admin team not the clinicians. If your scheme allows, consider using the morning/evening readings as outlined above. Conventional electronic sphygmomanometers are inexpensive and the figures produced by patients can be loaded into a spreadsheet by the admin team and the mean sent to the interpreting GP.
Some specifications allow for the morning/evening readings to be used where patients cannot tolerate having the automatic sphygmomanometer inflating every 30 minutes. It is worth having a low threshold for this and to consider whether it fits with the patient’s lifestyle. Confused patients may struggle and some find the discomfort of the cuff intolerable. An assessment of suitability needs to be done before the patient attends for fitting to ensure the ABPM machine is in constant use.
Remember NICE requires the daytime mean. Providing the machine is fitted at the first appointment of the morning, 08.00 or earlier, it can be removed at bedtime and still produce a valid result. Many patients find the automatic cuff disturbs sleep.
Most specifications will allow for follow-up patients. This means a known hypertensive who appears resistant to treatment can be retested to exclude white coat effect. This group can be forgotten but are often in scope for the service.
It is crucial to make sure the correct Read or SNOMED codes are used to trigger claims and it is worth having computer templates as a failsafe.
The claims should be monitored carefully and payment verified. It is worth auditing and considering all costs – particularly purchase and maintenance of equipment – to ensure the service is financially viable. If the service seems to be loss-making consider serving notice and contact your LMC who may be able to renegotiate with the commissioners.
Dr John Allingham is medical secretary at Kent LMC
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