Richard Smith: Why are we doing so badly with hypertension?

richard_smith_2014Forty years ago at medical school I learnt the “rule of halves” that states that among those with a chronic disease, like hypertension, half are diagnosed, half of those diagnosed are treated, and half of those treated are treated adequately. Last week I learnt at a meeting organised by Public Health England that England has five million people with hypertension that is undiagnosed and that of all those with hypertension only 37% are adequately treated compared with 66% in Canada. Why, I wondered, are we doing so badly with an age old problem?

The reason is not that we don’t know how to treat hypertension or that it is expensive to treat. We know that people should lose weight, eat less salt, drink less alcohol, and exercise more, although we also know that people find it hard to change their lifestyle. We do have effective drugs, many of which are off patent and cheap, although we have perhaps been slow to recognise that most people need to be treated with at least two drugs. We have also learnt that we should treat total risk of cardiovascular disease not just blood pressure (hypertension) or blood sugar (diabetes), but we continue to cling to single “diseases” like hypertension and diabetes.

Perhaps we are not doing as badly as we think. We may be doing badly in detecting and treating hypertension, a surrogate, but we are not doing badly in reducing heart attacks and strokes and lengthening life, the outcomes we are trying to achieve by treating hypertension. Heart attacks and strokes have fallen dramatically from when I was junior doctor, and people are older when they do have them; and life expectancy has increased considerably. These improvements are due in part to healthcare and public health but probably have more to do with shifting patterns of disease and broader social and economic changes.

But assuming that we do want to prevent and treat hypertension why are we doing so badly and how could we do better?

It’s tempting to blame individuals, but that would be a mistake. The task of detecting and treating hypertension lies with general practitioners, and, although it is generally low (37%), there is wide variation among practices in the percentage of people with hypertension who are treated. So we might blame GPs, particularly those in practices that are doing the worst. Or we might blame the population, who simply don’t understand hypertension, or the people who never go to the doctor or the half of patients who stop taking their drugs after a while.

Blaming individuals and demanding that they “do better” won’t get us anywhere, and even incentivising individual practitioners to detect and treat hypertension—as through the Quality and Outcomes Framework—hasn’t got us far.

The answer to why we have done so badly is that we have gone about it the wrong way, using the wrong “system.” We have left it to doctors and individual practices to do what they can, and while some have done well many have done indifferently.

We need a systematic population approach that doesn’t depend so much on doctors and individual practices. We need ironically to “demedicalise” the response to hypertension, as was said repeatedly at the NHS England meeting. Demedicalisation seems to have been at least part of the success in Canada.

Firstly, we need to find ways, probably multiple ways, to raise public understanding of hypertension. People don’t have symptoms and don’t know how dangerous it is. Even well educated people think that they can’t have hypertension because they don’t have palpitations, flushes, or headaches. People go to doctors with coughs, aching muscles and joints, and being “tired all the time,” which is largely a waste of everybody’s time, and don’t go to have their blood pressure tested. And even when they are treated they often don’t understand why they are being treated and that they have to take the treatment every day forever.

Secondly, people shouldn’t have to go the doctor to have their blood pressure measured. Most of the blood pressure measurements in Canada are not done in doctors’ clinics but in pharmacies, supermarkets, gyms, wherever. Increasingly people should measure and monitor their own blood pressure. Your blood pressure should not be your doctor’s problem but your problem.

Thirdly, why not move away from doctors altogether? Treating hypertension is not complicated. The guidelines are simple, but sadly many doctors don’t follow them—sticking instead with what they’ve learnt at medical school or what they’ve been doing for the past 15 years. Pharmacists could certainly manage hypertension if they could prescribe, and most people (I don’t like to call them patients) could probably treat themselves more effectively than doctors if they could get the drugs. They have more incentive to treat themselves effectively in that it is them who will have the heart attack or stroke not the doctor.

Fourthly, we need a population approach. We have good data on how badly practices and Clinical Commissioning Groups are doing, but who is accountable for improvement and has the levers to pull to do better? Some at the meeting thought that the appearance of accountable care organisations might help.

We could, fifthly, try a wholly different approach. I’m 63 and I don’t know my blood pressure, but I have for the past eight years taken three antihypertensive drugs at half dose together with a statin in a polypill. The drug comes through the post every three months once I have completed a questionnaire on possible side effects. I do have a GP (or at least a practice), but I virtually never go—and, like many men, I hate to go and wouldn’t take the polypill if I had to go the doctor’s every three months or so. It’s all I can do to get my hair cut. I think that many people, particularly men, would prefer this approach.

Sadly, it’s comparatively easy to see defects in a system and to think of what might be a better system, but to move from what we have now to a better system is formidably hard—there are too many vested interests, and the resources that are needed for a better system are tied up in the old system. The problem of doing better with hypertension is part of the problem of the whole NHS—we have a system designed for the problems of the mid 20th century struggling to respond to those of the 21st century.

Richard Smith was the editor of The BMJ until 2004.