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In their comprehensive review of recent advances in cardiology in primary care, Fahey and Schroeder1 looked at new models of care including nurse-led management of hypertension. We analysed trials from UK general practices of change in systolic blood pressure after a nurse-led intervention until 2002. These showed a combined reduction in systolic blood pressure of only 3mm Hg — a fall that could just be due to accommodation.2 By contrast the landmark American Hypertension Detection and Follow-up trial showed that an organised system of regular follow up and review of hypertensive patients using a stepped care approach to treatment reduced not only blood pressure but also mortality over 5 years.3 The vital difference between this and the British community-based trials is that it included change in drug treatment to achieve target blood pressure.
The introduction of quality payments is encouraging UK general practices to improve management of people with high blood pressure. Although not yet tested in randomised trials, it is likely that this will involve an enhanced role for practice nurses. This could include adherence to protocols, agreed target blood pressure, better prescribing and compliance, and regular follow up.4 The development of supplementary prescribing by practice nurses will also be important. What a pity that the new NICE (National Institute of Clinical Excellence) recommendations for management of hypertension in primary care fail to include the simple, user-friendly British Hypertension Society ABCD guidelines.5