Shared learning database

East Berkshire CCG
Published date:
February 2018

It was identified within East Berkshire that there were a large number of people with undiagnosed hypertension. In order to reach a diagnosis rate comparable to the best in England, a total of 13,069 people would need to be found and diagnosed.

The CCG Medicines Optimisation Team (MOT) developed a strategy to support practices in finding people who either had hypertension or were at risk of developing hypertension through systematic audit. Over 12 months the audit was delivered in all 48 practices in East Berkshire. MOT Pharmacists then added people with hypertension to disease registers or referred people not yet diagnosed for diagnosis as set out in CG127 and QRISK assessment as set out in CG181.

After 12 months, there was an increase in 6,167 people recorded as having hypertension in East Berkshire. This was a 12% increase in the number of people diagnosed with hypertension, a significantly higher increase than in the previous two years (1% and 3%). It was also a bigger increase than any other CCG in England in 2015/16 or 2016/17.

This example was originally submitted to demonstrate implementation of NICE guideline CG127. The guideline has now been updated and replaced by NG136. The example has been reviewed and practice it describes remains consistent with BP targets in the updated guidance. The updated guideline should be referred to if replicating any aspect of this example.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim was to increase diagnosis rates for hypertension within East Berkshire.


  • To identify people with hypertension or at risk of hypertension who were not currently recorded as having hypertension,
  • To ensure that these people receive a diagnosis of hypertension as appropriate.

Reasons for implementing your project

The CCGs in East Berkshire cover a population of 453,000 people. Within the area there is a significant range of demographics: there are areas of deprivation and areas of affluence, areas with mixed older and younger populations and there are areas with high proportion of black and minority ethnic (BME) residents. If a method of working can be proven successful across the area then it is likely to be successful in most areas of the country.

An analysis was carried out by public health locally that showed that the current recorded prevalence of hypertension was 55% of the expected prevalence. This was significantly lower than the best performing areas in England where diagnosis rates are at 70%. The England average was 59%.

Failing to diagnose and manage hypertension has a significant cost. Locally it was estimated that each additional person who had their hypertension identified and managed would save £250 in health and social care costs over the next 5 years.

How did you implement the project

Our project utilised currently employed members of the CCG Medicines Optimisation Team (MOT). This team has longstanding relationships with local GP practices that mean that they can deliver projects in every practice. This is built upon trust and a shared understanding of how to work together efficiently and effectively.

The MOT have experience of using GP clinical systems and this expertise was essential in developing the case finding searches that were used during the project. The searches used criteria such as: a) “find registered patients who are currently prescribed and antihypertensive and have a blood pressure recorded as greater than 140/90 but do not have a diagnosis of hypertension recorded”; b) “find registered patients who have two previous blood pressure results above 150/90”.

This was included within the MOT’s annual work plan. Each pharmacist was able to carry out the audit and additions to the hypertension register in each practice visited within one day i.e. 7.5 hours per practice.

Each GP practice was offered the opportunity to sign up to a hypertension case-finding locally commissioned service. This paid the GP practice £0.10 per registered patient if an increase in the size of their hypertension register of 5% was achieved. As part of the LCS practices were also asked to write a plan for how they were going to find people with hypertension over and above the systematic audit process provided by the MOT.

Key findings

In every practice visited the pharmacist recorded the number of people on the hypertension register prior to the project. Then they recorded the number of people that they added to the register as a result of the systematic case finding.

The results are as follows:

  • Number of practices where work completed = 48.
  • Number of practices where hypertension disease register increased = 48.
  • Total number of people on hypertension register prior to project = 51,279.
  • Total number of people added to hypertension register = 6,167.
  • Total number of people on hypertension register after project = 57,446.
  • Percentage increase in number of people on hypertension register = 12.03%.

Expectations were exceeded because the aspiration was to achieve a 10% increase in register size and an increase of 12.03% was achieved. This is bigger than any increase seen in any CCG in 2015/16 or 2016/17 (source. QOF achievement data, HSCIC).

The people identified will all receive follow-up and treatment in line with the Quality Outcomes Framework and NICE guidance for hypertension diagnosis and management. When blood pressure target achievement was measured in December 2017, 69.53% (4,288) of the group added to the hypertension register in 2017 were achieving a blood pressure of 150/90 or less. It is forecast that this will increase by the end of March 2018.

If the public health estimate of £250 saving over 5 years per person with hypertension who is identified and treated, then the potential saving would be 4,288 x £250 = £1,072,000.

GP practices were very pleased with the outcomes and the process was regarded as being efficient and not burdensome.

Key learning points

Systematic audit of GP clinical systems is a relatively easy way of identifying people with hypertension or at risk of hypertension but not yet diagnosed.

By using pharmacists from the Medicines Optimisation Team who have pre-existing relationships with practices it was possible to deliver this project in every local practice within one year. It may be possible to deliver it quicker if this was the only project being worked on, rather than being part of the annual work plan along with other projects. However, this would need to be balanced against the risks of using staff not known to practices (lower chance of 100% delivery) or the lost opportunity cost from not undertaking other pieces of work.

It would be possible to create the searches and then send them to GP practices to review and action themselves. This would likely require a payment to be made to each practice. It may lead to non-uniform implementation.

Contact details

Tim Langran
CCG Lead Prescribing Support Pharmacist
East Berkshire CCG

Primary care
Is the example industry-sponsored in any way?