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Hypertension

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What is covered

This interactive flowchart covers the clinical management of primary hypertension in adults.
High blood pressure (hypertension) is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state.
Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. Hypertension is remarkably common in the UK and the prevalence is strongly influenced by age. In any individual person, systolic and/or diastolic blood pressures may be elevated. Diastolic pressure is more commonly elevated in people younger than 50. With ageing, systolic hypertension becomes a more significant problem, as a result of progressive stiffening and loss of compliance of larger arteries. At least one quarter of adults (and more than half of those older than 60) have high blood pressure.

Updates

Updates to this interactive flowchart

27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
27 October 2015 Implanting a baroreceptor stimulation device for resistant hypertension (NICE interventional procedures guidance 533) added to step 4 resistant hypertension.
21 August 2015 Interactive flowchart restructured and summarised recommendations replaced with full recommendations.
20 March 2013 Hypertension in adults (NICE quality standard 28) added.
15 January 2013 WatchBP Home A for opportunistically detecting atrial fibrillation during diagnosis and monitoring of hypertension (NICE medical technologies guidance 13) added to measuring blood pressure.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on managing hypertension in adults in an interactive flowchart

What is covered

This interactive flowchart covers the clinical management of primary hypertension in adults.
High blood pressure (hypertension) is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state.
Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. Hypertension is remarkably common in the UK and the prevalence is strongly influenced by age. In any individual person, systolic and/or diastolic blood pressures may be elevated. Diastolic pressure is more commonly elevated in people younger than 50. With ageing, systolic hypertension becomes a more significant problem, as a result of progressive stiffening and loss of compliance of larger arteries. At least one quarter of adults (and more than half of those older than 60) have high blood pressure.

Updates

Updates to this interactive flowchart

27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
27 October 2015 Implanting a baroreceptor stimulation device for resistant hypertension (NICE interventional procedures guidance 533) added to step 4 resistant hypertension.
21 August 2015 Interactive flowchart restructured and summarised recommendations replaced with full recommendations.
20 March 2013 Hypertension in adults (NICE quality standard 28) added.
15 January 2013 WatchBP Home A for opportunistically detecting atrial fibrillation during diagnosis and monitoring of hypertension (NICE medical technologies guidance 13) added to measuring blood pressure.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Hypertension in adults: diagnosis and management (2011 updated 2016) NICE guideline CG127
Implanting a baroreceptor stimulation device for resistant hypertension (2015) NICE interventional procedures guidance 533
Air pollution: outdoor air quality and health (2019) NICE quality standard 181
Hypertension in adults (2013 updated 2015) NICE quality standard 28

Quality standards

Air pollution: outdoor air quality and health

These quality statements are taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statements

Diagnosis – ambulatory blood pressure monitoring

This quality statement is taken from the hypertension in adults quality standard. The quality standard defines clinical best practice for hypertension in adults and should be read in full.

Quality statement

People with suspected hypertension are offered ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension.

Rationale

ABPM is the most accurate method for confirming a diagnosis of hypertension, and its use should reduce unnecessary treatment in people who do not have true hypertension. ABPM has also been shown to be superior to other methods of multiple blood pressure measurement for predicting blood pressure-related clinical events.

Quality measure

Structure
Evidence of local arrangements to ensure people with suspected hypertension are offered ABPM to confirm a diagnosis of hypertension.
Process
Proportion of people with suspected hypertension who receive ABPM to confirm a diagnosis of hypertension.
Numerator – the number of people in the denominator who receive ABPM to confirm a diagnosis of hypertension.
Denominator – the number of people with suspected hypertension.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to offer ABPM to confirm a diagnosis of hypertension.
Healthcare professionals offer ABPM to confirm a diagnosis of hypertension.
Commissioners ensure they commission services that offer ABPM to confirm a diagnosis of hypertension.
People with suspected hypertension (high blood pressure) are offered ambulatory blood pressure monitoring (which involves wearing a blood pressure monitor during their normal waking hours) to confirm whether or not they have hypertension.

Source clinical guideline references

NICE clinical guideline 127 recommendation 1.2.3 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 127 clinical audit tool: diagnosing hypertension, criterion 1.

Definitions

Ambulatory blood pressure monitoring (ABPM)
Clinical guideline 127 Hypertension: full guideline: Ambulatory blood pressure monitoring (ABPM) involves a cuff and bladder connected to electronic sensors which detect changes in cuff pressure and allow blood pressure to be measured oscillometrically. Systolic and diastolic pressure readings are deduced from the shape of oscillometric pressure changes using an algorithm built into the measuring device. A patient's blood pressure can be automatically measured at repeated intervals throughout the day and night, while they continue routine activities. Systolic and diastolic pressure can be plotted over time, with most devices providing average day, night and 24-hour pressures. NICE recommends recording a daytime average to confirm diagnosis.
Suspected hypertension
NICE clinical guideline 127 recommendation 1.2.3 describes suspected hypertension as clinic blood pressure of 140/90 mmHg or higher without a confirmed diagnosis of hypertension.

Equality and diversity considerations

ABPM may not be suitable for everyone, for example people with particular learning or physical disabilities. Some people may be unable to tolerate ABPM and some people may decline it.
Home blood pressure monitoring should be offered as an alternative to ABPM in such cases, in line with NICE clinical guideline 127 recommendation 1.2.4. If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension.

Investigations for target organ damage

This quality statement is taken from the hypertension in adults quality standard. The quality standard defines clinical best practice for hypertension in adults and should be read in full.

Quality statement

People with newly diagnosed hypertension receive investigations for target organ damage within 1 month of diagnosis.

Rationale

Assessment of target organ damage can alert the clinician to possible secondary causes of hypertension, some of which are potentially life threatening and some that may be amenable to potentially curative interventions. It can also support the clinician to decide the appropriate blood pressure threshold at which to consider drug therapy for the treatment of hypertension.

Quality measure

Structure
Evidence of local arrangements for people with newly diagnosed hypertension to receive all investigations for target organ damage within 1 month of diagnosis.
Process
Proportion of people with newly diagnosed hypertension who receive all investigations for target organ damage within 1 month of diagnosis.
Numerator – the number of people in the denominator who receive all investigations for target organ damage within 1 month of diagnosis.
Denominator – the number of people with newly diagnosed hypertension.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with newly diagnosed hypertension to receive all investigations for target organ damage within 1 month of diagnosis.
Healthcare professionals carry out all investigations for target organ damage for people with newly diagnosed hypertension within 1 month of diagnosis.
Commissioners ensure they commission services that carry out all investigations for target organ damage for people with newly diagnosed hypertension within 1 month of diagnosis.
People with newly diagnosed hypertension (high blood pressure) receive tests within 1 month of being diagnosed to check for any damage to organs such as their eyes, heart or kidneys.

Source clinical guideline references

NICE clinical guideline 127 recommendations 1.2.6 and 1.3.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 127 clinical audit tool: diagnosing hypertension, criterion 3.

Definitions

Investigations for target organ damage
NICE clinical guideline 127 recommendation 1.3.3 recommends that for all people with hypertension, healthcare professionals should offer to:
  • test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
  • take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
  • examine the fundi for the presence of hypertensive retinopathy
  • arrange for a 12-lead electrocardiograph to be performed.
Target organ damage
NICE clinical guideline 127 recommendation 1.2.6 lists left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy as examples of target organ damage.

Statin therapy

This quality statement is taken from the hypertension in adults quality standard. The quality standard defines clinical best practice for hypertension in adults and should be read in full.

Quality statement

Quality statement 3 has been replaced by quality statements on primary and secondary prevention of cardiovascular disease in cardiovascular risk assessment and lipid modification (NICE quality standard 100).

Blood pressure targets

This quality statement is taken from the hypertension in adults quality standard. The quality standard defines clinical best practice for hypertension in adults and should be read in full.

Quality statement

People with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg if aged under 80 years, or below 150/90 mmHg if aged 80 years and over.

Rationale

Hypertension is associated with a higher risk of cardiovascular events. Setting blood pressure to recommended levels aims to promote primary and secondary prevention of cardiovascular disease, and to lower the risk of cardiovascular events.

Quality measure

Structure
a) Evidence of local arrangements to ensure people aged under 80 years with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg.
b) Evidence of local arrangements to ensure people aged 80 years and over with treated hypertension have a clinic blood pressure target set to below 150/90 mmHg.
Outcome
People with treated hypertension whose target blood pressure is achieved.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people aged under 80 years with treated hypertension to have a clinic blood pressure target set to below 140/90 mmHg, and for people aged 80 years and over with treated hypertension to have a clinic blood pressure target set to below 150/90 mmHg.
Healthcare professionals ensure that people aged under 80 years with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg, and people aged 80 years and over with treated hypertension have a clinic blood pressure target set to below 150/90 mmHg.
Commissioners ensure they commission services that have arrangements for people aged under 80 years with treated hypertension to have a clinic blood pressure target set to below 140/90 mmHg, and for people aged 80 years and over with treated hypertension to have a clinic blood pressure target set to below 150/90 mmHg.
People who are receiving treatment for hypertension (high blood pressure) have a target clinic blood pressure (blood pressure measured in their GP practice or clinic) below 140/90 mmHg if they are aged under 80 years, or a clinic blood pressure below 150/90 mmHg if they are aged 80 years or over.

Source clinical guideline references

NICE clinical guideline 127 recommendations 1.5.5 and 1.5.6.

Data source

Structure
a) and b) Local data collection.
Outcome
Quality and Outcomes Framework (QOF) indicator HYP002:The percentage of patients with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 150/90 mmHg or less.
Quality and Outcomes Framework (QOF) indicator HYP003:The percentage of patients aged 79 and under with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 140/90 mmHg or less.

Definitions

Clinic blood pressure
Clinic blood pressure refers to blood pressure measured in the clinic.
For a clinic blood pressure of 140/90 mmHg, the corresponding ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg.
For a clinic blood pressure of 160/100 mmHg or higher, the corresponding ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Treated hypertension
Treated hypertension includes treatment with antihypertensive drugs.

Equality and diversity considerations

Targets are based on evidence of safe practice. A person aged 80 years or over with treated hypertension would not have a target clinic blood pressure of 150/90 mmHg if their blood pressure was already treated to below this threshold.

Review of cardiovascular disease risk factors

This quality statement is taken from the hypertension in adults quality standard. The quality standard defines clinical best practice for hypertension in adults and should be read in full.

Quality statement

People with hypertension are offered a review of risk factors for cardiovascular disease annually.

Rationale

People’s blood pressure and cardiovascular disease risk will increase over time. A review of risk factors for cardiovascular disease delivered as part of an annual review of care should support identification of increased risk and provide an opportunity to address modifiable risk factors.

Quality measure

Structure
Evidence of local arrangements to ensure people with hypertension are offered a review of risk factors for cardiovascular disease annually.
Process
Proportion of people who have had hypertension for 12 months or longer who have had a review of risk factors for cardiovascular disease within the past 12 months.
Numerator – the number of people in the denominator who have had a review of risk factors for cardiovascular disease within the past 12 months.
Denominator – the number of people who have had hypertension for 12 months or longer who do not have established cardiovascular disease.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to offer people with hypertension a review of risk factors for cardiovascular disease annually.
Healthcare professionals offer people with hypertension a review of risk factors for cardiovascular disease annually.
Commissioners ensure they commission services that offer people with hypertension a review of risk factors for cardiovascular disease annually.
People with hypertension (high blood pressure) are offered a review of risk factors for cardiovascular disease annually.

Source clinical guideline references

NICE clinical guideline 127 recommendation 1.7.3.

Data source

Structure
Local data collection.
Process
Quality and Outcomes Framework (QOF) indicator CVD-PP02: The percentage of patients diagnosed with hypertension (diagnosed on or after 1 April 2009) who are given lifestyle advice in the preceding 12 months for: smoking cessation, safe alcohol consumption and healthy diet.
Quality and Outcomes Framework (QOF) indicator SMOK005: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months?

Definitions

Annual review of care
NICE clinical guideline 127 recommendation 1.7.3 recommends that an annual review of care should be provided to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication.
Review of risk factors for cardiovascular disease
Review of risk factors for cardiovascular disease could include:
  • smoking status
  • alcohol consumption
  • blood pressure
  • body mass index or other measure of obesity
  • total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides
  • blood glucose
  • renal function
  • liver function (transaminases) if receiving statins
  • heart rate and rhythm (pulse measurement).
(adapted from NICE clinical guideline 67 recommendation 1.4.2).
Blood pressure should be measured more frequently than annually for patients who need more frequent monitoring.

Referral to a specialist for people with resistant hypertension

This quality statement is taken from the hypertension in adults quality standard. The quality standard defines clinical best practice for hypertension in adults and should be read in full.

Quality statement

People with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled are referred for specialist assessment.

Rationale

People with resistant hypertension will usually be at high risk of cardiovascular disease. Specialist assessment and evaluation supports management of their condition.

Quality measure

Structure
Evidence of local arrangements for people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled to be referred for specialist assessment.
Process
Proportion of people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled who are referred for specialist assessment.
Numerator – the number of people in the denominator who are referred for specialist assessment.
Denominator – the number of people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled.

Description of what the quality statement means for each audience

Service providers ensure local arrangements are in place for people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled to be referred for specialist assessment.
Healthcare professionals refer people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled for specialist assessment.
Commissioners ensure they commission services that refer people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled for specialist assessment.
People with resistant hypertension (high blood pressure that is difficult to control) who are receiving 4 antihypertensive drugs (drugs to treat high blood pressure) and whose blood pressure is still high are referred for a specialist assessment.

Source clinical guideline references

NICE clinical guideline 127 recommendations 1.6.18 and 1.6.22.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Referral for specialist assessment
Referral should be to a healthcare professional, usually in secondary care, with specialist expertise in high blood pressure.
Resistant hypertension
NICE clinical guideline 127 recommendation 1.6.18 recommends that clinic blood pressure that remains higher than 140/90 mmHg despite step 3 treatment with the optimal or best tolerated doses of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) plus a calcium-channel blocker (CCB) plus a diuretic should be regarded as resistant hypertension. People aged 80 years and over are considered to have resistant hypertension if their clinic blood pressure remains higher than 150/90 mmHg despite optimal or best tolerated doses of step 3 treatment.
Recommendation 1.6.22 recommends that expert advice should be sought if blood pressure remains uncontrolled with step 4 treatment of optimal or maximum tolerated doses of 4 drugs if expert advice has not yet been obtained.

Strategic plans

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution.

Rationale

Local authorities should be strategic leaders of local initiatives to address air pollution, working in a coordinated way with key partners to ensure a consistent and planned approach. Identifying their approach to air pollution in the Local Plan, local transport plan and other key strategies will provide a clear framework for joined-up local action. The key components of their approach should include enabling zero- and low-emission travel (including active travel such as cycling or walking) and developing buildings and spaces to reduce exposure to air pollution.

Quality measures

Structure
a) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including who is responsible for delivering key actions.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
b) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable active travel.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
c) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable travel by zero- and low-emission vehicles.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
d) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will develop buildings and spaces to reduce exposure to air pollution.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
e) Evidence that local authorities identify key actions to address air pollution and monitor progress against them.
Data source: Local data collection, for example, progress on actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local authorities work with partners to ensure the Local Plan, local transport plan, and other key strategies identify the approach to addressing air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution. Local authorities work together to prevent migration of traffic and emissions to other communities, which may result in areas of poor air quality.
People in the community know that their local authority and other local organisations are working together to protect them from the effects of air pollution.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.1.1, 1.1.2 and 1.1.3

Definitions of terms used in this quality statement

Local authorities
All tiers of local government including county, district and unitary authorities, as well as regional bodies and transport authorities.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1]
Other key strategies
Relevant local strategies, such as the air quality action plan, commissioning and procurement strategy, core strategy, environment strategy, and health and wellbeing strategy.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and expert opinion]
Zero- and low-emission travel
Includes cycling and walking; travel by zero- and low-emission vehicles such as electric cars, buses, bikes and pedal cycles; and car sharing schemes or clubs.
[Adapted from NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and terms used in this guideline]
Developing buildings and spaces to reduce exposure to air pollution
This could include:
  • siting and designing new buildings, facilities and estates to reduce the need for motorised travel
  • minimising the exposure of vulnerable groups to air pollution by not siting buildings (such as schools, nurseries and care homes) in areas where pollution levels will be high
  • siting living accommodation away from roadsides
  • avoiding the creation of street and building configurations (such as deep street canyons) that encourage pollution to build up where people spend time
  • including landscape features such as appropriate species of trees and vegetation in open spaces or as 'green' walls or roofs where this does not restrict ventilation
  • considering how structures such as buildings and other physical barriers will affect the distribution of air pollutants.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.2]

Equality and diversity considerations

Local authorities should ensure that strategic plans identify areas where air pollution is highest and, in particular, locations where people who are vulnerable to air pollution may be exposed to high levels of air pollution, such as schools, nurseries, hospitals and care homes, so that targeted approaches can be put in place.
Local authorities should ensure that they assess the impact on vulnerable groups if local charges on certain classes of vehicle in clean air zones are proposed. If necessary, actions to mitigate the impact of charges on specific groups should be identified.

Planning applications

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.

Rationale

The built environment can affect the emission of road-traffic-related air pollutants by influencing how and how much people travel, for example, by ensuring good connections to walking and cycling networks. Buildings can affect the way air pollutants are dispersed through street design and the resulting impact on air flow. Addressing air pollution at the planning stage for major developments may reduce the need for more expensive remedial action at a later stage. It can also help to maintain people’s health and wellbeing during and after construction. Assessing proposals to minimise and mitigate road-traffic-related air pollution will help to ensure they are robust and evidence based.

Quality measures

Structure
a) Evidence of local processes and guidance that ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution.
Data source: Local data collection, for example, review of supplementary planning guidance.
b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.
Data source: Local data collection, for example, review of supplementary planning guidance.
Process
Proportion of planning applications for major developments granted permission with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Numerator – the number in the denominator with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Denominator – the number of planning applications for major developments granted permission.
Data source: Local data collection, for example, local planning application system.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local planning authorities ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution during and after construction. Local planning authorities provide guidance for applicants and have a clear framework for assessing proposals in line with the Local Plan, local transport plan and other key strategies. Local guidance should make it clear that proposals to minimise or mitigate road-traffic-related air pollution must be evidence based. Local planning authorities monitor compliance with planning conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Local authority planning officers assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments using an agreed local framework to ensure they are evidence based. Local authority planning officers encourage applicants to modify their planning applications if necessary, to include evidence-based approaches to minimise or mitigate road-traffic-related air pollution.
Planning applicants for major developments know that the local planning authority will assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications to ensure they are evidence based. Planning applicants can get information on what the local planning authority is looking for and how the proposals will be assessed. Planning applicants for major developments modify their application to improve the approach to minimising or mitigating road-traffic-related air pollution if required by the local authority.
People in the community know that their local planning authorities require developers to show how they will minimise road-traffic-related air pollution and improve local air quality around big building projects when they apply for planning permission. This is to help protect local people from the effects of air pollution on their health.

Source guidance

Definitions of terms used in this quality statement

Major developments
Development involving any one or more of the following:
  • the winning and working of minerals or the use of land for mineral-working deposits
  • waste development
  • the provision of dwelling houses where:
    • the number of dwelling houses to be provided is 10 or more or
    • the development is to be carried out on a site having an area of 0.5 hectares or more and the number of dwelling houses is not known
  • the provision of a building or buildings where the floor space to be created by the development is 1,000 square metres or more or
  • development carried out on a site having an area of 1 hectare or more.

Equality and diversity considerations

Local planning authorities should ensure that proposals to encourage active travel in planning applications for major developments are accessible to people with limited mobility or disabilities.

Reducing emissions from public sector vehicle fleets

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Public sector organisations reduce emissions from their vehicle fleets to address air pollution.

Rationale

The public sector fleet is substantial and includes various vehicle types, some of which are highly polluting. Reducing emissions from public sector vehicle fleets will help to reduce road-traffic-related air pollution. Public sector organisations can extend their impact by commissioning transport or fleet services from organisations that reduce emissions from their vehicle fleets to address air pollution. By publicising their approach, public sector organisations can encourage organisations in other sectors to take action to reduce emissions from their vehicle fleets.

Quality measures

Structure
a) Evidence that public sector organisations identify how they will reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, a plan to reduce fleet emissions. Organisations could use the Sustainable Development Unit’s Health Outcomes of Travel Tool (HOTT) to develop a plan.
b) Evidence that public sector organisations require commissioned transport or fleet services to reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, commissioning specifications. Commissioning specifications could require adherence to the Department for Environment, Food and Rural Affairs’ Government Buying Standards for transport.
Outcome
a) Proportion of zero- or ultra-low-emission vehicles in public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.
b) Overall fuel consumption for public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.

What the quality statement means for different audiences

Service providers (such as local authorities, NHS trusts, police and fire and rescue services) develop a plan for how they will reduce emissions from their vehicle fleet to address air pollution and monitor the impact of the plan on vehicle type and total fleet CO2 emissions. Providers consider a range of approaches including:
  • replacing vehicles with zero- or ultra-low-emission vehicles over time
  • incentives to lease zero- or ultra-low-emission vehicles
  • training drivers to change their driving style
  • consolidating and sharing vehicles to ensure efficient use
  • action to minimise congestion caused by delivery schedules
  • specifying emission standards for private hire and other licensed vehicles.
Public sector fleet managers support the development and monitoring of a plan to reduce emissions from the vehicle fleet to address air pollution. Public sector fleet managers ensure that staff are aware of the plan and take action in line with the priorities identified.
Commissioners (such as local authorities, clinical commissioning groups, NHS England, and police and crime commissioners) ensure that commissioned transport or fleet services have a plan for how they will reduce emissions from their vehicle fleet to address air pollution and ensure providers monitor the impact of their plan on vehicle type and total fleet CO2 emissions.
People in the community know that public sector organisations are working to reduce pollution from their vehicles. This will help to reduce local air pollution and protect people from the effects on their health.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.4.1, 1.4.2, 1.4.3 and 1.4.6

Advice for people with chronic respiratory or cardiovascular conditions

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Children, young people and adults with chronic respiratory or cardiovascular conditions are given advice at routine health appointments on what to do when outdoor air quality is poor.

Rationale

Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admissions to hospital. Providing advice to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments will support self-management, improve their awareness of how to protect themselves when outdoor air quality is poor and prevent their condition escalating.

Quality measures

Structure
a) Evidence that healthcare professionals carrying out routine health appointments with children, young people and adults with chronic respiratory or cardiovascular conditions are aware of the advice they should provide on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, training records.
b) Evidence of local processes to ensure that children, young people and adults with chronic respiratory or cardiovascular conditions attending routine health appointments are given advice on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, service protocols.
Process
Proportion of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment that were given advice on what to do when outdoor air quality is poor.
Numerator – the number in the denominator that were given advice on what to do when outdoor air quality is poor.
Denominator – the number of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment.
Data source: Local data collection, for example, audit of patient records.
Outcome
a) Level of awareness among children, young people and adults with chronic respiratory or cardiovascular conditions on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, survey of children, young people and adults with chronic respiratory or cardiovascular conditions.
b) Rate of hospital attendance or admission for respiratory or cardiovascular exacerbations.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attacks, acute chronic obstructive pulmonary disease exacerbations, heart attacks, strokes, heart failure and angina attacks.

What the quality statement means for different audiences

Service providers (such as general practices, community health services, hospitals and community pharmacies) ensure that healthcare professionals are aware that information on air quality is available, what it means and what actions are recommended. Service providers ensure that processes are in place to provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments. Providers ensure that advice includes how to find out when outdoor air quality is expected to be poor such as from the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Healthcare professionals (such as doctors, nurses, healthcare assistants and pharmacists) provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions who are attending a routine health appointment (and their families and carers, if appropriate). They also provide information on how to find out when outdoor air quality is expected to be poor, for example using the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Commissioners (such as clinical commissioning groups and NHS England) commission services that provide advice on what to do when outdoor air quality is poor to children, young people and adults (and their families and carers, if appropriate) at routine health appointments.
People with long-term breathing or heart conditions (and their family and carers, if appropriate) are given advice at routine health appointments on what to do when outdoor air quality is poor and how to find out when it is likely to be poor.

Source guidance

Definitions of terms used in this quality statement

Routine health appointments
Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions.
[Expert opinion]
Advice on what to do when outdoor air quality is poor
Advice should include how to minimise exposure to outdoor air pollution and manage any related symptoms such as:
  • Avoiding or reducing strenuous activity outside, especially in highly polluted locations such as busy streets, and particularly if experiencing symptoms such as sore eyes, a cough or sore throat.
  • Using an asthma reliever inhaler more often, as needed.
  • Closing external doors and windows facing a busy street at times when traffic is heavy or congested to help stop highly polluted air getting in.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.7.7 and the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]
Poor outdoor air quality
The Daily Air Quality Index describes air pollution on a scale of 1 to 10 and is divided into 4 bands from low to very high. Health effects may occur when air pollution is moderate (4 to 6), high (7 to 9) or very high (10).
[The Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

angiotensin-converting enzyme inhibitor
angiotensin II receptor blocker
calcium-channel blocker
ambulatory blood pressure monitoring
estimated glomerular filtration rate
home blood pressure monitoring
clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher
clinic blood pressure 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 135/85 mmHg or higher
clinic blood pressure 160/100 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 150/95 mmHg or higher
a discrepancy of more than 20/10 mmHg between clinic and average daytime ambulatory blood pressure monitoring or average home blood pressure monitoring measurements at the time of diagnosis

Paths in this pathway

Pathway created: August 2011 Last updated: June 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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