Hypertension

Community Control of High Blood Pressure, Third Edition

Hart Julian Tudor

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781870905824
• eBook ISBN:
  9781315343808
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Fully updated and revised Differential Diagnosis in Dermatology Third Edition now includes sections on treatment as well as serving as a useful guide to dermatological diagnosis in the surgery or clinic. It takes the reader through the process of diagnosing skin disease from the basic biology of skin history taking describing skin lesions and carrying out special investigations. This book provides excellent clinical photography practical text and clear diagrams throughout. Chapters are divided into different body areas and possible diagnosis can be made by reading through the text or looking through the photographs.

1

Size and Shape of the Task

• The Rule of Halves
• NHS ‘reform’ and the 1990 Contract
• Anglo-American contrasts
• Means and ends
• Size and sign of the gross medical product
• Constructive doubt
• Blood pressure control as a model for continuing population care

Neither treatment nor understanding of the causes of high blood pressure have changed fundamentally since the first edition of this book in 1979. There have been incremental advances on most fronts, but nothing dramatic. What really has changed is appreciation of the size of the task, and the impossibility of dealing with it only through hospital based specialists. Because high blood pressure is normally an asyptomatic condition, some form of systematic population wide screening or case finding with follow-up is essential.

It is now generally accepted that management of uncomplicated high blood pressure implies continuing care of some sort (with or without medication) for between 10 and 30% of the adult population. The problem is greater in older and poorer populations, and less in the younger or more affluent. The sheer size of the problem precludes routine management in hospital clinics.

Continuity and a personal approach are now generally recognized as essential for good control and minimal drop-out, and these should be easier to provide at the centre of a community than at its periphery. We have come to accept a curiously inverted terminology in this respect, regarding district hospitals as more central than primary care, and tertiary super-specialist hospitals as more central still, and may ask: central to what and to whom? That depends on where we think life really goes on.

It is now also generally accepted that high blood pressure is rarely an isolated risk, and cannot be effectively managed as though it were. It is nonsensical to ignore or refer outside the primary care team the routine management of associated cardiovascular risks such as smoking or glucose intolerance, which also require generalist rather than specialist skills.

Finally, there is consensus agreement, at least in theory, that management of high blood pressure should begin, not with antihypertensive drugs, but with other measures to reduce either blood pressure itself, or its consequent risks.

I say these advances are ‘generally accepted’, but what does this actually mean? Just as most people are content to celebrate on the sabbath a code of ethical behaviour they ignore for the rest of the week, advances in whole population care may be used more as a guide to right answers for examinations than as useful and necessary standard medical practice. When Whitfield and Bucks¹ asked GPs in the Bristol area, only 45% said they would always accept responsibility for management of moderately high blood pressure in the diastolic range 110–120 mmHg. Full acceptance of responsibility was not associated with age, so it was not just a matter of replacing tired old men with energetic young ones.

The Rule of Halves

Studies of what general practitioners (GP)s actually do, as opposed to what they say or know, have been even more damning. The Rule of Halves^2,3 is alive and well, at least in the UK.

• Half the people with high blood pressure are not known.
• Half those known are not treated.
• Half those treated are not controlled.

As an order of magnitude, the Rule still held in the North East of Scotland in 1984–6 for men aged 40–59 years⁴.

Figure 1.1 maps the consequences of hypertension, and of its still frequently neglected control, in England and Wales⁵ and in Scotland. It shows a roughly threefold variation in the burden on both patients and health workers, which broadly parallels every other kind of social and economic disadvantage. Between 1961 and 1981, professional men in England and Wales enjoyed falls in mortality of 79% for hypertensive disease, and 60% for cerebrovascular disease. In contrast, the mean falls for semiskilled and unskilled men were 56% and 15% respectively⁶ Ascertainment and management of high blood pressure evidently improved, but advance was, as usual, greatest where needs were least and care was most comfortable⁷. The Glasgow Western Infirmary’s acute stroke unit admits about 300 unselected patients a year from a catchment population of 220 000. In 1992, of 351 patients with information on antecedent diagnosis and treatment, 132 had previously diagnosed hypertension but only 62 of these (47%) were receiving antihypertensive medication: of 58 aged under 70 years, only 27 (also 47%) were medicated⁸.

Ascertainment and management have improved. The situation was worse when I reviewed it in 1987 for the second edition, and worse still in 1979 when I wrote the first. Throughout those years the average number of staff employed by UK GPs remained virtually unchanged, at 1.2 whole time equivalent staff per principal⁹. Teamwork, the key to effective care of populations, remained sabbath rhetoric, not everyday practice.

Figure 1.1 Deaths directly attributed to hypertension and/or stroke in England and Wales 1982–6. Standardized mortality ratios, England and Wales = 100⁵. (Reproduced with permission from the Controller of Her Majesty’s Stationery Office.)

NHS ‘Reform’ and the 1990 Contract

The recent ‘reform’ of the UK National Health Service is typical of a worldwide abdication from co-operative public service and retreat to competitive marketed care, masked by accelerated advance toward rational health promotion¹⁰. The 1990 GP Contract, by linking practice income with ‘health promotion’ clinics and 3-yearly ‘health checks’, pushed many practices into activity. In West Glamorgan, before the 1990 Contract there were only about 10 ‘health promotion’ clinics a week, other than antenatal or children’s clinics; less than a year later there were 315, roughly one for each GP. In England, 94% of practices were running health promotion clinics by the end of the first year of the contract, and by 1991 the average was about two per practice. ‘For all of these, high blood pressure was the favourite target.

The 1990 Contract paid for the first time for proactive care of populations, requiring a population approach, with more staff and more delegation of work. By 1991, three out of four practices had a practice manager, and 88% employed one or more practice nurses.

Before the 1990 Contract, a study of 14 training practices¹¹, of which nine employed a practice nurse and five did not, showed no difference between the with-nurse and without-nurse practices in the proportion of patients over 40 years with blood pressures recorded during the preceding 5 years (about 50% in both). This showed that measurements were not being delegated. Numerous studies have established that nurses, after suitable training, are usually able to measure blood pressures more accurately than doctors¹².

The many GPs I know who shared this passivity all had the same excuses; they hadn’t enough time to read books or original papers, or to reorganize their practices to make full use of available skills. Many doubted the capacity of nurses to perform simple diagnostic tasks or to take clinical decisions, and most denied the value of standard protocols or algorithms for management of uncomplicated cases. Now the Contract appears not only to have solved all these problems of undertreatment at one stroke, but replaced them with new problems of reckless intervention, already familiar in the USA. Many ‘health promotion’ clinics now seem to be supervised almost wholly by practice nurses, with hardly a doctor in sight, although serious in-service education of these nurses for more or less autonomous decision making has (at the time of writing) scarcely begun in most areas.

Anglo-American Contrasts

The Rule of Halves, first described in the USA in the early 1970s, had disappeared there by the 1980s, at least in insured populations, for two reasons.

First, there was an energetic national campaign of professional and public education, led by outstanding, nationally known specialists and backed by campaigning public organizations. American cardiologists, for example Oglesby Paul, Paul Dudley White and Jerry Stamler, had a long and honourable tradition of public leadership. Their popular approach still seems inconceivable to most of their peers in the UK. Our gentlemanly tradition seems to have led to disbelief in the intelligence and educability of ordinary people.

Secondly, in the USA activism was accelerated by dollars. In their system of state subsidized private insurance, medical activity generated fees; in our salary and capitation based National Health Service, it generated taxes. Excessive displays of clinical energy were expensive to the exchequer, and difficult for family doctors who were unwilling either to employ a full team or to share responsibility with it. Restrained by capitation rather than spurred on by fees, UK GPs tended to maintain income through permanently excessive work-loads, so that consultations were too short to get beyond satisfaction of wants, towards an active search for needs.

Means and Ends

Encouraged by this evidence that incentives do motivate, policy planners have pushed NHS practice towards that in the USA. If process is paid for, process will be obtained. The trouble is, medical science ultimately concerns not process but outcome, not means but ends. Will more health promotion clinics or health checks mean better care, and therefore fewer heart failures, strokes, myocardial infarctions, and premature deaths?

We do have some evidence that process can safely be used in this way as a proxy for outcome. In all industrialized countries, even with the generally inadequate care provided since large scale treatment of high blood pressure became possible in the late 1950s, first malignant hypertension, then acute left ventricular failure, once fairly common events, became rarities. Both were usually consequences of years rather than months of neglect of severe but often asymptomatic high blood pressure. Neglect on that scale is now unusual. One way or another, most severe cases get recognized, by accident if not by design, because arterial pressures are measured more often, not only by GPs, but by insurance doctors, hospital staff, in antenatal clinics, in chemist’s shops and even in airport waiting lounges. In a fumbling way, most of these worst cases get treatment somehow or other, before an artery blow...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Foreword to the First Edition
• Foreword to the Third Edition
• Preface
• 1 Size and Shape of the Task
• 2 Nature, Mechanisms and Causes of Primary High Blood Pressure
• 3 Secondary High Blood Pressure
• 4 Iatrogenesis
• 5 Natural History and Complications
• 6 Thresholds for Follow-Up and Medication
• 7 High Blood Pressure as a Combination Risk Factor
• 8 Case Finding and Screening
• 9 Record Systems
• 10 Measurements
• 11 Divisions of Labour
• 12 Investigation and initial assessment
• 13 Organization of Follow-up and Compliance
• 14 Referral and the Interface Between Primary and Secondary Care
• 15 Management Without Medication
• 16 Antihypertensive Medication in General
• 17 Specific Antihypertensive Drugs
• 18 Refractory and Complicated Cases, and Hypertensive Emergencies
• 19 High Blood Pressure in Childhood and Adolescence, and the Origins of Adult Disease in Childhood
• 20 High Blood Pressure in Young Adults
• 21 High Blood Pressure in the Elderly
• Appendices