Long-term conditions (LTCs), such as diabetes and arthritis, are those for which there is no cure and that are usually managed with drugs and other treatment measures (Department of Health and Social Care (DHSC), 2012). Around 15 million people in England have one or more LTC, accounting for 70% of healthcare expenditure (House of Commons Health Committee, 2014), and this figure is rising. In addition to this, the NHS is dealing with an ageing population and ongoing staffing issues. It is easy to see why, as a result, the organisation has been described as overwhelmed and in a humanitarian crisis; at times, these pressures have led to frustrated patients with LTCs who receive care that is inconsistent and fragmented (Care Quality Commission (CQC), 2018).
In a recent appearance, distinguished public sector leader Lord Bichard (2018) described how care will improve with ‘more joined-up services’ and by ‘devolving power away from the state’. Similarly, Croisdale-Appleby (2018) described the absolute necessity for integrated health and social care to improve the provision of care. The disjointed way of sharing information about a patient across the many branches of the healthcare system is not efficient or helpful for the patient (DHSC, 2012). High-quality care should be provided to people living with LTCs by shared management of the caseload across care settings and multidisciplinary teams.
Improving care for LTCs
Ambitious plans for change to improve the management of LTCs are underway. With the development of ‘50 vanguards’ as part of the NHS Five Year Forward View, sustainability and transformation partnerships and integrated care systems, the hope is that more coordinated, joined-up care can be delivered (DHSC, 2018b).
In 2013, the King's Fund published a significant document (Coulter et al, 2013), which stated that:
‘Management of care for people with long-term conditions should be proactive, preventive and patient-centred’.
The authors argued that in doing so, health professionals will encourage self-management, with care focused around shared decision-making between the patient and multidisciplinary team. The metaphor ‘house of care’ (Coulter et al, p. 1) is used to represent the ultimate goal: delivering joined-up care, with people living with LTCs at the centre.
Managing hypertension
Hypertension is a LTC that affects 30% of UK adults (British Heart Foundation, 2018). A person is hypertensive when they have a blood pressure of 140/90 mmHg or above, which can lead to increased pressure to the heart or blood vessels, potentially resulting in heart attack, stroke or other complications. In 95% of cases, there is no single identifiable cause for hypertension. However, it is widely accepted that blood pressure can increase with age and lifestyle factors. Despite hypertension being the third biggest risk factor for disease in the UK and the largest single risk factor for cardiovascular disease (CVD), diagnosis and management of the condition is suboptimal (Coyle et al, 2019). Given these factors, and the prevalence of hypertension and its association with other diseases, more focus is needed on preventing this condition.
Preventative, person-centred care
The recently published NHS Long Term Plan (2019) focuses heavily on prevention. Prevention is about ‘helping people stay healthy, happy and independent for as long as possible’ (DHSC, 2018a). In relation to hypertension, it is estimated that, over 10 years, 45 000 lives could be saved in England if a 5 mmHg reduction in the average systolic blood pressure were achieved (Public Health England, 2014). High blood pressure can be prevented or reduced by making lifestyle changes. A meta-analysis by the National Institute for Health and Care Excellence (NICE) (2011) found that the most important lifestyle interventions for reducing blood pressure were weight loss through diet, changes to diet and exercise and salt reduction.
By considering the necessary lifestyle interventions needed for change, some successful national preventative schemes were developed in recent years, including the National Salt Reduction Programme’ and Public Health England's ‘Food Smart App’. Results from the salt reduction programme, for example, showed a 15% reduction in salt intake in England over a decade, resulting in a fall in blood pressure between 2003 and 2011. This is considered to have contributed substantially to a decrease in hypertension-related stroke mortality (He et al, 2014).
Other preventative interventions have focused heavily on increasing awareness of hypertension. British Heart Foundation's free helpline and NHS Right Care's CVD prevention pathway have been influential. The CVD prevention pathway involves commissioning more ambulatory blood pressure monitoring services and self-test units (for example, in surgery waiting rooms, leisure centres and football pitches) for nurses, doctors and other health professionals to encourage free access to these services by the general public. Preventative schemes such as these are aiming to transcend boundaries between health and social care provision by reaching a greater number of prospective patients and enabling monitoring in social settings. They also provide care that is centred around the patient, allowing patients access to their own health information when it is convenient for them.
Unfortunately, initiatives like these are not reaching everyone. For some individuals, existing health inequalities make it difficult for them to successfully manage blood pressure. For example, in England, women with low household incomes are more likely to be obese (NHS Digital, 2014), and salt consumption is higher among ethnic minorities, young people and lower socio-economic groups (Ji and Cappuccio, 2014). In fact, people living in more deprived areas in England are 30% more likely to be hypertensive than those in least deprived areas (Public Health England, 2014).
The Government is trying to address these inequalities, and has recently promised increased funding for areas with high health inequalities in the Long Term Plan (NHS England, 2019). Public Health England (2014) called upon Marmot's (2010) review for help. Marmot identified two principals involved in confronting health inequalities: proportionate universalism (actions taken universally with an intensity that is proportionate to the level of disadvantage) and targeted efforts to establish healthy habits in younger people. Programmes, such as the NHS health check, are reaching some. Robson et al (2017) showed that health check attendance increased between 2009 and 2014 to 85% in disadvantaged populations in London, compared with 50% nationally, leading to a 50% increase in the diagnosis of hypertension. Looking more closely at the uptake of the NHS health check however, there is a reported low number of participants from some communities, such as black and minority ethnic groups, who are known to be at greater risk of CVD. This has caused concern that the NHS programme may actually increase health inequalities in some places (Artac et al, 2013). A study by Riley et al (2015) looked at these findings and tested the effectiveness of developing targeted community outreach NHS Health Checks for Afro-Caribbean communities in inner-city Bristol. The results revealed how a combination of local health partnerships (health trainers and family practice staff) and community assets (community centres, church groups, and informal networks) coming together at appropriate times and places can increase the uptake of NHS health checks in these targeted areas. Perhaps the district or community nursing teams could also be influential in increasing participation in such outreach screening events, by advertising to and encouraging attendance by friends and families of the patients they care for.
One community nurse, dubbed the ‘Spurs nurse’ (Ford, 2016) was reportedly giving health checks to football fans in North London, as part of the ‘community health checks scheme’. This initiative, primarily aimed at men aged over 35 years, who are usually reluctant to visit their GP, has assessed and advised over 4000 people in the community so far. These targeted community schemes offer person-centred care to individuals who may not be able to attend more conventional medical settings, offering access to hard-to-reach populations.
In Gloucestershire, preventing hypertension is considered a high priority (Gloucestershire Clinical Commissioning Group, 2016). Successful initiatives already trialled as part of the ‘Gloucestershire prevention and self-care plan’ (Gloucester County Council, 2013) include a community weight management service, supporting 12 000 patients; surgeries offering opportunistic health checks to registered carers; and ‘social prescribing’, supporting 1000 individuals to self-care and engage with community support. Gloucestershire has one of the largest social prescribing programmes (Gloucester County Council, 2013), with GP practices accepting referrals from community nurses and social workers. The Gloucestershire Health and Wellbeing Board (2016) published a ‘health inequalities action plan’, highlighting how it aims to reduce inequalities with wide-ranging interventions. This document also recognises the importance of the Marmot review (2010) on addressing health inequalities, and work is ongoing.
Focusing on prevention is undoubtedly an important approach to tackle the prevalence of hypertension in the UK. However, more can be done for those individuals already living with hypertension and associated conditions.
Proactive, person-centred care
Proactive care is about managing LTCs so that patients can stay active and well for as long as possible (Coulter et al, 2013). For patients with hypertension, it is largely about managing their blood pressure to help prevent the onset of other related diseases. In providing proactive care, it is important to first understand the physical, psychological and social implications of living with disease. Hypertension, during its early stages, is usually without symptoms. However, these may develop with subsequent related diseases, such as coronary disease, cerebrovascular disease and renal failure. The effects of hypertension and the potential loss of activities of daily life can lead to anxiety and depression, and it is estimated that 30% of people with a LTC have a mental health problem (Naylor et al, 2012). Social and psychological support, including from family, friends and the wider community, is considered to have a significant effect on the ability of individuals to cope and recover. The King's Fund (Edwards, 2014) highlighted how community teams, including nurses, will be instrumental in helping to identify and care for these individuals, as well as making referrals to mental health providers. A variety of online networks, such as the Blood Pressure Support Services and the British Heart Foundation, are also important in providing support and advice for people, and community nursing staff are in the ideal position to signpost patients to these.
As well as community-based social, physical and psychological support, it is widely recognised that self-management should form an important part of proactive care-planning (Coulter et al, 2013). The need to explore how valuable self-management can be is palpable when considering that approximately 80–90% of all care for people with the LTC multiple sclerosis is undertaken by the patient or their family (Multiple Sclerosis Trust, 2011). Self-management requires patients to be proactive, while working in partnership with health professionals. By self-managing, a patient can experience greater confidence in their health and wellbeing as well as help to lower healthcare utilisation, reducing the strain on primary and secondary care. Training carers to encourage self management is also helpful to the patient, improving quality-of-life and self-confidence in both patient and carer. Community nurses play an important role in this process. Massimi et al (2017)'s systematic review and meta-analysis of the role of self-management in the process of caring for patients with LTCs showed that nurses in the community can be more effective than other health professionals in improving blood pressure control. They found that this effect was more pronounced when nurses were specifically trained, and when face-to-face interventions were involved.
However, care should be taken, when self-managing. Patients can experience motivational and environmental barriers, such as the temptation of readily available, cheap, unhealthy foods when trying to manage diet. A good clinician will identify a patient's barriers and work with them and their carers to address these.
In Gloucestershire, self-management is a priority. The new programme ‘Gloucestershire Self-Management’ enables patients and carers to meet others living with LTCs to explore common problems (Gloucestershire Care Services NHS Trust, 2018a). ‘Complex Care at Home’, another local service encouraging self-management, provides proactive identification of adults who are losing their independence, enabling appropriate measures to be implemented (Gloucestershire Care Services NHS Trust, 2018b). Experienced teams of district nurses, specialist nurses, wellbeing practitioners, carers and allied health professionals provide a holistic approach, ensuring the social, physiological and physical wellbeing of the patient.
Self-management complements the use of assistive technology in providing proactive person-centred care. A study by Stoke-on-Trent Clinical Commissioning Group (2012) showed the benefits of telehealth for managing hypertension. Patients found the system easy to use, supportive and preferential to a surgery visit, because it allowed self-care to occur when it suited them. A recent investment in telehealth and telecare in Gloucestershire is hoping to provide proactive, preventative care for people with LTCs in the county. Community nurses will be involved in delivering this care, in teams such as Complex Care at Home, working alongside GP practices. A growing body of evidence supports the use of these technologies. However, there are associated risks, for example, lack of clinician engagement, that must be considered.
Other avenues that patients are exploring to be proactive in managing their LTCs include complementary therapies such as garlic extract, meditation and yoga. A number of reviews examining the benefits of these kinds of techniques suggest that further exploration is needed (Grant et al, 2012). Some researchers consider evidence to be limited in this area, given the lack of large randomised controlled trials. However, these trials can be costly, and finances may not be readily available for this kind of research when compared with pharmaceutical investigations. There may still be more that can be learnt from complementary therapies to help people living with hypertension reduce their blood pressure.
Conclusion
This article has identified a number of initiatives that are preventative, proactive and person-centred in managing care for people at risk of, or already living with, hypertension. Many of these initiatives are already underway in parts of the UK. For example, in Gloucestershire, successful, local enterprises such as ‘Complex Care at Home’ are working to provide care focused around self-management of hypertension and other related diseases, alongside integrated community healthcare teams, enabling patients to remain in their homes. Such schemes subscribe to the key components of the ‘house of care’ model as well as the main aims of the NHS Long Term Plan (NHS England, 2019): to offer proactive, person-centred management of care for people with LTCs. Further work is needed to ensure that similar care is provided for all individuals living with LTCs, across the county of Gloucestershire and the rest of the UK.
In terms of furthering prevention, until the significant underestimation of efforts needed to help those with existing health inequalities is addressed, the prevalence of hypertension and other LTCs will continue to rise among these individuals. A more focused approach towards those who are disadvantaged and targeted efforts to establish healthy habits in young people are needed to reduce the prevalence of LTCs in these populations. Programmes such as the NHS health check need to be targeted towards communities where health inequalities are common, to help screen more of the population. Multidisciplinary community teams are needed to do this, involving nurses, social workers and key community figures, working together at appropriate times and places, to reach as many people as possible.