Locally commissioned services

Pharmacy teams should also be aware of locally commissioned services to support lifestyle changes and be able to signpost people accordingly. Onward referral to a social prescriber at a GP surgery may be an option in some areas, for instance. Always remember that the potential effects on blood pressure from lifestyle interventions will be additive:

• Weight management: Ideally to achieve/maintain a BMI of 18.5-24.9m2. It is estimated that systolic blood pressure (SBP) will reduce by 3mmHg for every 4-8 per cent reduction in bodyweight
• Increasing exercise: Regular aerobic activity of at least 30 minutes/day can reduce SBP by 4-9mmHg
• Eating for a healthy heart: A diet rich in fruit and vegetables with low-fat dairy and overall reduced fat intake can reduce SBP by 8-14mmHg. There is evidence for this dietary approach from the Dietary Advice to Stop Hypertension (DASH) diet trial
• Alcohol reduction: Advice should be in line with recommendations for alcohol intake of no more that 14 units per week. Moderation of alcohol intake may reduce SBP by 2-4mmHg
• Reducing salt intake: Cutting down on salt consumption may reduce SBP by 2-8mmHg. It is advised that adults should eat no more that 6g of salt (2,400mg of sodium) a day.This is around one teaspoonful. Simple ways to reduce intake include avoiding adding salt at the table, and using herbs or spices to flavour food instead. The use of salt substitutes is generally not recommended as they tend to be high in potassium. This may be a particular problem in people with kidney disease or for patients on ACE inhibitors, angiotensin receptor blockers, spironolactone or eplerenone leading to hyperkalaemia
• Smoking cessation: This does not reduce blood pressure per se but will have a positive impact on overall cardiovascular health and should always be considered alongside blood pressure lowering interventions.

People with raised blood pressure should be referred to their GP in line with an agreed SOP with the GP practice(s), which will also define the criteria for same-day and urgent referral to the GP. The methods of communication should be standardised. 

The GP practice will be responsible for further evaluation of people referred for same-day and urgent referral as well as any patients newly diagnosed with hypertension. This should be in line with national guidelines for the diagnosis and treatment of hypertension. The GP may refer the patient back to the pharmacy for subsequent ongoing blood pressure monitoring.

If medication is needed for blood pressure management, this will be under the direction of the GP practice. Increasingly, the practice-based or PCN pharmacist may be the lead within the GP surgery for this cohort of patients, and building a relationship between the pharmacy and GP surgery will be helpful to both parties.

Pharmacists should use any opportunity to support lifestyle interventions and medication adherence for people with high blood pressure. Patients in England on hypertension medication are eligible for the new medicine service. 

Reflection exercise

A patient approaches you in the pharmacy for advice on buying a blood pressure monitor. What information would you give regarding what type to buy? What advice would you give regarding using a blood pressure monitor at home?