The National Institute for Clinical Excellence (NICE) has issued guidance on the treatment and care of patients with high blood pressure (hypertension) within the NHS in England and Wales.

Hypertension: management of hypertension in adults in primary care makes five key recommendations:

1) Measuring blood pressure
Patients with single raised blood pressure readings of more than 140/90mmHg should be asked to return for a minimum of two further blood pressure readings.

2) Assessing cardiovascular risk
Cardiovascular risk assessment should be conducted in hypertension patients to help identify diabetes, evidence of hypertensive damage to the heart and kidneys and secondary causes of hypertension such as kidney disease.

3) Lifestyle interventions
Lifestyle advice (eg, smoking cessation, diet, alcohol and caffeine consumption, exercise) should be offered initially and then periodically to patients undergoing assessment or treatment for hypertension.

4) Pharmacological interventions
Drug therapy should be offered to patients with persistent high blood pressure (160/100 mmHg or more) and patients at raised cardiovascular risk (eg, those with chronic heart disease, cardiovascular disease).

Recommendations are made for the use of thiazide-type diuretics, beta-blockers, ACE-inhibitors and dihydropyridine calcium-channel blockers.

5) Continuing treatment
An annual care review should be provided to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication. Patients without cardiovascular disease and with well-controlled blood pressure wishing to reduce or stop using drugs may be offered a trial reduction or withdrawal.

Forty per cent of British adults are believed to live with hypertension. However, of that figure it is estimated that a third are unaware of their condition because there are no obvious symptoms. NICE say this means it is often inadequately treated, while those that do suffer from it do not get the best treatment.

The need to address the problem is vital as high blood pressure is also a major contributor to cardiovascular diseases (eg, strokes and heart attacks), which account for four million NHS bed days and 30 per cent of all deaths annually.

It is predicted that the new guidelines’ recommendations to prescribe more could see a rise in drug costs. Anti-hypertensive drugs cost the NHS £840m in 2001 — almost 15 per cent of the primary care drugs budget.

Chief executive of NICE, Andrew Dillon said:

‘The aim of this guideline is to decrease morbidity and mortality resulting from cardiovascular diseases such as stroke, chronic renal failure and coronary heart disease for which hypertension is a significant risk factor. Hypertension can be treated, in most cases, successfully. The fact that a significant proportion of people with this condition remain undiagnosed, coupled with evidence that suggests a high incidence of sub-optimal treatment — and therefore poor rates of blood pressure control — for those who are diagnosed, make this guideline particularly significant.’

The Association of the British Pharmaceutical Industry (ABPI) welcomed the guidance, in particular the emphasis it places on the use of hypertension drugs. Dr Richard Barker, director general, said that it:

‘demonstrates once again that early and tight management of a disease results in better health for patients, reduces the number of hospital stays and frees up capacity for the NHS. Medicines have a key role to play in achieving these aims.’

The Newcastle guideline development and research unit (NGDRU) contributed to the finished guidelines, which NICE asks local health communities to read and then review their existing clinical guidelines, care pathways and protocols.

Patients who dial 999 for a non-urgent problem, such as a cut finger or earache, may be visited by a nurse instead of an ambulance.

Health minister Rosie Winterton announced that from October strategic health authorities, primary care trusts and local ambulance trusts would be responsible for monitoring non-urgent or category C calls and for setting performance requirements for dealing with them. At present, these are dealt with at a national level.

Ambulance trusts are already gearing up for change. Initiatives include:

• Nurses, paramedics and emergency care practitioners treat patients at home so they don't have to go to hospital
• In Staffordshire, mental health advisers assess cases where appropriate and patients are referred to crisis intervention teams
• Links with NHS Direct so patients can get advice over the phone

Ambulances will still be expected to reach urgent calls in under 14 minutes in urban areas and under 19 minutes in rural areas. Rosie Winterton also praised the service for reaching more than 75 per cent of calls in less than eight minutes.

GPs are lobbying the government to introduce fines for patients who fail to keep appointments. It is thought that no shows are costing the NHS £162m a year.

Research by health education charity Developing Patient Partnerships (DPP) surveyed more than 700 GPs and calculated that there were 8.8 million missed GP appointments in Britain last year and 3.9 missed practice nurse appointments.

Two thirds of the nation's practices thought charging patients for missed appointments would help. A fine of less than £10 was backed by 47 per cent and 17 per cent wanted a fine of more than £10.

The total of missed appointments is down from the previous year — DPP reported 12.7 missed GP appointments. But it is felt that now the majority of practices are meeting the government target of appointments within 48 hours, failing to turn up is less excusable.

GPs were asked why they thought patients missed appointments:

• Forgetfulness — 67 per cent
• Feeling better — 26 per cent
• Failure to get through and cancel the appointment — 1.2 per cent

DPP feels that public education is key. Spokesman Terry John and colleagues at his practice in Waltham Forest, London, note missed appointments on patients' records and raise the problem at the next visit.

Stroke patients are being let down because too few hospitals have specialist units to treat them according to the Royal College of Physicians.

In a survey repeated every two years since 1998, the college studied 256 acute hospitals in England, Wales, Northern Ireland and the Channel Islands and found that just 201 of them had stroke units. The Channel Islands and Wales were particularly short.

There has been improvement, however. Ten years ago there were almost no specialist stroke units in NHS hospitals. At the last survey two years ago, 73 per cent of hospitals in England had a specialist unit. Now the figure is 82 per cent.

All hospitals in England were supposed to have a unit by April this year. There is no requirement for the rest of the UK, but in Ireland 11 out of 13 acute hospitals have services.

Other findings include:

• Patients who have mini-strokes need to be seen by a specialist within days rather than weeks to prevent them having a full stroke. Only half of hospitals are able to see patients within 14 days.
• There are huge variations in care available to stroke patients after leaving hospital. Just 27 per cent of hospitals in England and five per cent of hospitals in Wales have community teams. In Northern Ireland the figure was 23 per cent and in the Channel Islands it was 33 per cent.

The poaching of healthcare staff from developing countries is to be addressed in a new code on international recruitment.

Almost 180 agencies are signed up to the current code that restricts recruitment from over 150 developing countries, including areas of Africa and Asia.

The new proposals will:

• offer private sector employers NHS international recruitment programmes to reduce ‘back door’ recruitment into the NHS
• close the loophole allowing healthcare providers to bring in locum and temporary staff from developing countries
• extend the code to around 200 more agencies that work with the NHS on domestic recruitment (currently only agencies supplying overseas healthcare staff have to comply with the code)

In announcing the shake-up, health minister John Hutton said:

‘We are determined not to destabilise the healthcare system of developing countries. The NHS is expanding, but we're not going to do that at the expense of other countries. We are working with the private sector to ensure it follows the NHS' example.

‘These proposals will strengthen the code even further, bring the private sector into line with the NHS and will ensure that, as with independent treatment centres, NHS contracts go to those signed up to the code.

‘We’re also proposing closing the loophole that allows trusts to recruit temporary staff from developing countries and extending the code to cover even more recruitment agencies.’

The revised code should be published later this year.