One in three adults in the United Kingdom has high blood pressure. It remains the single biggest modifiable risk factor for stroke, heart attack and kidney failure.
At a time when we are rightly focused on pressures facing the NHS, the challenges of an ageing population and the cost of treating preventable conditions, it is worth considering whether our policy framework on one of the country’s most common and serious conditions is keeping pace with developments in clinical evidence.
Last week, I raised an oral question in the House of Lords on resistant hypertension and the support available for patients who do not respond to standard treatments. The response from the minister was, in several respects, encouraging. NHS England is reviewing the clinical evidence for renal denervation. The forthcoming Cardiovascular Disease Modern Service Framework will refer to resistant hypertension as a distinct category. The government has also set an ambition to reduce premature mortality from heart disease and stroke by 25 per cent over the next decade.
These are all welcomed steps. At the same time, it is important that ambition is matched by timely and effective delivery. For a particular group of patients, delays in doing so may have significant consequences. Many people with high blood pressure can be managed, at least in part, through lifestyle changes and medication.
Resistant hypertension is different. It describes a condition in which blood pressure does not respond adequately to three or more drugs, and sometimes four. As Lord Patel explained in the chamber with characteristic clinical clarity, it involves a malfunction in the interaction between the sympathetic nervous system, the kidneys and the brain. It is not simply a question of patient adherence or primary care oversight. It is a distinct, higher-risk clinical subgroup that requires specialist management.
Between five and ten percent of people with hypertension are thought to have the resistant form. Although that may sound like a relatively small proportion, in the context of how widespread hypertension is, it represents a very substantial number of people. Many may not yet be receiving the most appropriate care, not because there are no effective options, but because commissioning arrangements have not fully caught up with the evidence.
Renal denervation is a minimally invasive procedure that targets the renal sympathetic nerves, disrupting one of the pathways that drives elevated blood pressure. The UK expert clinical consensus, published in the journal Heart, concluded that existing commissioning arrangements no longer reflect the strength of the current evidence base. NICE has recognised the procedure as a potential treatment option, yet access remains uneven and is still shaped by special arrangements that vary by geography.
Lord Evans of Rainow asked the Lords whether the government were concerned about a postcode lottery. It would be fair to say that variation in access is already a real worry, and one that merits careful attention.
Procedures such as renal denervation, supported by specialist medical device providers who have invested significantly in developing and evidencing this technology, are not theoretical futures. They are available now, in clinical practice, in hospitals across Europe. What remains to be addressed in England is the commissioning clarity needed to ensure that eligible patients can access them consistently, regardless of where they live.
This is also, importantly, an issue of equity. Baroness Pidgeon was right to highlight prevention and management in communities with the highest prevalence and poorest outcomes. Hypertension is disproportionately prevalent in South Asian and Black communities, in areas of economic deprivation, in populations that already face higher barriers to accessing timely specialist care.
When treatment pathways are unclear, eligibility criteria vary, and referral routes depend on information moving smoothly through a fragmented system, it is often the most disadvantaged patients who are least well served.Detection has expanded, but the information often fails to reach the right place, leaving people undertreated as well as underdiagnosed.
The government’s move from sickness to prevention is one of the three central pillars of the ten-year health plan and I support that direction entirely. But prevention alone cannot meet the needs of people who are already living with resistant hypertension and are not responding to standard treatment. For these patients, the priority must now be access to the most effective care available, delivered through specialist centres by clinicians able to consider the full range of options, including denervation where appropriate.
Baroness Winterton of Doncaster suggested that an NHS research-led pilot on renal denervation pathways could help strengthen the evidence for specialist care. Building on that point, I would look to the forthcoming Modern Service Framework to go further still, explicitly recognising resistant hypertension as a high-risk subgroup. The commissioning review currently under way at NHS England must result in clear, consistent and nationally applicable criteria. And the Government must set out a timeline for when patients and clinicians can expect that clarity to arrive.
For patients waiting to learn whether a treatment their clinicians believe may help them will become consistently available on the NHS, these are not simply technical policy questions. They have a direct bearing on health, quality of life and the risk of serious preventable events. The opportunity to act is there; the task now is to turn that opportunity into progress.
Content from our partners
Related
