Management guidelines in essential hypertension: report ofthesecond working party ofthe British Hypertension Society

Peter Sever, Gareth Beevers, Christopher Bulpitt, Anthony Lever, Larry Ramsay, John Reid,John Swales

Department ofClinicalPharmacology andTherapeutics, QueenElizabeth the QueenMother Wing, St Mary'sHospital Medical School,Imperial College ofScience, Technology,and Medicine, LondonW2 INYPeter Sever, professor;chairman ofsecond workingparty

Department ofMedicine,Dudley Road Hospital,Birmingham B18 7QHGareth Beevers, reader

Department ofGeriatricMedicine, RoyalPostgraduate MedicalSchool, HammersmithHospital, LondonW12 ONNChristopher Bulpitt,professor

Medical Research CouncilBlood Pressure Unit,Western Infirmary,Glasgow Gil 6NTAnthony Lever, professor

Department ofPharmacology andTherapeutics, UniversityofSheffield, RoyalHallamshire Hospital,Sheffield S1O 20JFLarry Ramsay, professor

Department ofMedicineand Therapeutics,Gardiner Institute,Western Infirmary,Glasgow Gil 6NTJohn Reid, professor

Department ofMedicine,Clinical Sciences Building,Leicester Royal Infirmary,PO Box 65, LeicesterLE2 7LXJohn Swales, professor

Correspondence to:Professor Sever.

BMJY 1993;306:983-7

Several important new issues have arisen in themanagement of patients with hypertension. Aworking party of the British Hypertension Societyhas therefore reviewed available intervention studieson anti-hypertensive treatment and made recom-mendations on blood pressure thresholds for inter-vention, on non-pharmacological and pharma-cological treatments, and on treatment goals. Thisreport also provides guidelines on blood pressuremeasurement, essential investigations, referrals forspecialist advice, follow up, and stopping treatment.

In 1989 a British Hypertension Society working partyproduced recommendations on the drug treatment ofhypertension' based on an analysis of the availableintervention trials. In several aspects different recom-mendations have been made by the Joint NationalCommittee on Detection, Evaluation, and TreatmentofHigh Blood Pressure in the United States2 and in thejoint guidelines of the World Health Organisation andIntemational Society of Hypertension.3 All thesegroups are revising their advice and the British Hyper-tension Society established a second working party toconsider issues relating to the current management ofhypertension-particularly those arising from recenttrials in elderly hypertensive patients;'-and theemerging evidence that drug treatment may reducecoronary events in addition to preventing strokes.There are two main issues on which lack of evidence

leads to uncertainty. These are the blood pressurebelow which hypertension does not warrant treatmentand the type of drugs to be used initially whentreatment is justified. Thus until better evidence isavailable arbitrary and interim recommendations are

needed. These issues and other management recom-mendations are dealt with below.

Blood pressure measurementBritish Hypertension Society guidelines on measur-

ing blood pressure should be followed.7 In assessingthresholds several recordings should be obtained-forexample, two or more in the sitting position on eachvisit on up to four separate occasions. In mild hyper-tension and in older patients with isolated systolichypertension but no target organ damage measure-

ments should be repeated over three to six months.

With more severe hypertension the delay is necessarilyshorter. Standing pressures must also be measured inelderly people and patients with diabetes because of thepotential problem of orthostatic hypertension.

Non-pharmacological treatmentNon-pharmacological measures play an important

part in any blood pressure control programme andshould be offered to all hypertensive patients whethertaking drugs or not. This advice should also be offeredto people with a strong family history of hypertension.In mild hypertension non-pharmacological measures

may obviate the need for drugs. In the treatmentof mild hypertension study a combination of non-pharmacological measures reduced blood pressure by10O5/8-2 mm Hg and drug regimens produced falls of18-2/12-8 mm Hg.' In patients with higher bloodpressures non-pharmacological measures may

facilitate blood pressure reduction with lower doses ofdrugs or, in some patients, reduce the need formultiple drug regimens. Advice should includemeasures to reduce coexisting risk factors for cardio-vascular disease, which occur commonly in hyperten-sive subjects. Lifestyle modifications may be listed as

follows.For blood pressure lowering lifestyle modifications

should include (a) a reduction in total energy intake toachieve ideal body weight; (b) avoidance of excessivealcohol intake (recommend <21 units per week inmales and 14 units per week in females), with somealcohol free days each week (see below); (c) a reductionin salt intake by eliminating the use of table salt,reducing the use of salt when preparing food, andavoiding excessively salt foods; and (d) regular physicalexercise and improving the overall level of fitness-forexample, in younger subjects by three training sessionsa week or jogging for 30 minutes three times a week,and in elderly people by increasing distances walked.(With respect to alcohol intake epidemiological datashow that high blood pressures are associated withhigher alcohol intake-that is >20 units per week.However, the recommendation for a lower intake isbased on national guidelines that take into accountadditional non-cardiovascular risks associated withalcohol ingestion.)For cardiovascular disease prevention lifestyle

modifications should include (a) stopping smoking;(b) a reduction in total energy intake to achieve idealbody weight; (c) avoidance of foods with high animal(saturated) fat and cholesterol content to be replacedby fish, fruit, and vegetables and polyunsaturated andmonounsaturated fatty acids; and (d) regular physicalexercise (see above).The successful introduction of non-pharmacological

measures to lower blood pressure and reduce cardio-vascular risk demands time and effort put in by thedoctor and by the practice nurse. When the facilities ofa dietitian are available this is a distinct advantage.Great emphasis should be placed on encouragingpatients to stop smoking as the coexistence of smokingas an additional risk factor in hypertensive patientsconfers a much increased risk of subsequent cardio-vascular events. In the Medical Research Council trialof treatment in mild hypertension the benefits of neverhaving smoked far outweighed the benefits of bloodpressure lowering.9 In the context of providing dietaryadvice to patients it is important to include other

BMJ VOLUME 306 10ApRtL1993

Blood pressure measurement* Follow British Hypertension Society guidelines relat-

ing to instruments, cuff sizes, and technique* Record two or more blood pressures at each visit* Record blood pressure on several occasions before

assessing thresholds

983

on 22 October 2020 by guest. P

rotected by copyright.http://w

ww

.bmj.com

/B

MJ: first published as 10.1136/bm

j.306.6883.983 on 10 April 1993. D

ownloaded from

members of the family in the discussion of modifieddietary measures when these include reducing salt andtotal energy.

Thresholds for intervention with drugsIn men and women of any age with malignant phase

hypertension the benefit of antihypertensive drugs isunequivocal and these should be initiated withoutdelay.'0 In severe hypertension (diastolic bloodpressure - 110 mm Hg) repeated measurementsshould be performed over a short period (one to twoweeks) to confirm a sustained increase in pressure anddrug treatment begun (fig 1).""1 Drug treatment

TREAT OBSERVEFIG 1-Thresholds for drug treatment of hypertension with reference todiastolic blood pressure. (All patients given non-pharmacologicaladvice.) *Repeated measurements

should also be started in patients whose diastolicpressure is recorded as 100-109 mm Hg on three or

more occasions over days or weeks and who haveevidence of target organ damage-for example, leftventricular hypertrophy, transient ischaemic attacks,previous stroke, angina or previous myocardial infarc-tion, renal impairment, or peripheral vascular disease.Patients who have diastolic pressures of 100-109 mmHg but no evidence of target organ damage should beobserved initially weekly and thereafter monthly.When there is a downward trend in blood pressure(diastolic pressure < 100 mm Hg) observation shouldbe continued together with non-pharmacological treat-ment. If raised blood pressure is sustained ( ¢ 100 mmHg) during this period drug treatment should bestarted.The management of patients whose diastolic blood

pressures remain between 90 and 99 mm Hg on

repeated measurement over three to six months iscontroversial. Although the risk of heart attack andstroke is increased in this blood pressure range,'3 1' the

risks and hence potential benefit of drug treatmentto individual patients may be relatively small. Theevidence of benefit from therapeutic intervention in allclasses of patients is not universally accepted.' Forexample, in those with target organ damage such as leftventricular hypertrophy, renal impairment, or

diabetes drug treament is indicated. In those withouttarget organ damage or diabetes but with a diastolicblood pressure within the range 90-99 mm Hg thedecision to treat is influenced by the following riskfactors, whose presence defines a higher risk group ofpatients who merit antihypertensive treatment. Therisk factors are higher pressures within the range,

advanced age, male sex, smoking, raised serum lipidconcentrations (dyslipidaemia; see below), or a strongfamily history of cardiovascular disease. However,even when a decision is made not to treat with drugsmonitoring of blood pressure with long term non-

pharmacological treatment is recommended.Prolonged observation is important in these circum-

stances because blood pressure after follow up in theuntreated state more precisely predicts risk than doesblood pressure measured at the outset. When bloodpressure does not fall during continuous observationthe case for treatment is stronger.

(Dyslipidaemia is defined as an abnormal serum lipidprofile which confers increased risk of atheroscleroticcardiovascular disease. The risk of coronary heartdisease conferred by a high serum cholesterol concen-tration varies with age and sex. A raised cholesterolvalue carries a relatively greater risk in men than inwomen and in youth than in old age. When relative riskof coronary heart disease is taken as the criterion valuesof serum cholesterol'5 are regarded as desirable whenbelow 5-2 mmol/l, borderline when between 5-2 and 6-4mmol/l, abnormal when between 6-5 and 7-8 mmol/l,and high risk when above 7-8 mmol/l. Higher totalcholesterol concentrations, however, should be con-

sidered in conjunction with measurements of highdensity lipoprotein cholesterol and triglyceridevalues.)Thus the threshold for therapeutic intervention with

drugs is influenced by an assessment of several factors,not simply the level of blood pressure. As stated above,all patients should receive non-pharmacological advicewith respect to blood pressure lowering and theprevention of atheroma. The risk of smoking and thebenefit in those who stop outweigh the benefit oftreating mild hypertension. Thus hypertensivepatients who smoke should be strongly urged to stopsmoking. When dyslipidaemia coexists with hyperten-sion attention should be paid to lowering lipid valuesby diet initially. If this fails, particularly in patientswith multiple risk factors for coronary heart disease,cholesterol lowering drugs should be considered.Guidelines on the management of dyslipidaemia bythese means have been published by British'6 and

European'7 societies.

Thresholds ofdiastolic blood pressure for interventionwith drugs in younger patients* 100 mm Hg-treat* 90-99 mm Hg-dependent on additional factors

Elderly hypertensive patientsRecent trials have consistently confirmed the bene-

fits of lowering the blood pressure in a population agedover 60.16 Both the SHEP and MRC trials6 providedevidence that coronary events, in addition to strokes,were reduced by drug treatment. Subgroup analysis ofthe MRC trial suggested that low dose diuretic treat-ment is preferred to ,3 blockers, at least in the over 60s

BMJ VOLUME 306 1O APRIL1993

Non-pharmacological treatment* Reduce energy intake* Avoid excessive alcohol* Reduce salt intake* Stop smoking* Avoid high saturated fat intake* Take regular exercise

984

on 22 October 2020 by guest. P

rotected by copyright.http://w

ww

.bmj.com

/B

MJ: first published as 10.1136/bm

j.306.6883.983 on 10 April 1993. D

ownloaded from

age group. Convincing evidence of the benefits oftreating very old people (over 80 years) is lacking.Therefore, no definitive recommendations can bemade for this subgroup of patients. It may be unwise tostop drug treatment in very old people unless bloodpressure is normal and close monitoring determinesthe effects of stopping treatment. From these trials theblood pressure readings above which therapeutic inter-vention is indicated are a sustained systolic pressure ofgreater than 160 mm Hg or a sustained diastolicpressure of greater than 90 mm Hg.

Elderly patients

* Benefit from drug treatment

* Threshold 3 160 mm Hg systolic blood pressure3 90 mm Hg diastolic blood pressure, or both

or

Isolated systolic hypertension in over 60s andsystolic thresholds in younger patientsThe results of the SHEP trial and in a subgroup

of elderly patients in the MRC trial suggest thattreating isolated systolic hypertension (systolicpressure greater than 160 mm Hg, diastolic pressureless than 90 mm Hg) is also beneficial in elderlypatients. Further trials are in progress to test this.In making an interim recommendation the BritishHypertension Society working party was aware thatthe SHEP study included a highly selected group of fitelderly hypertensive patients. Doctors should becautious in widening the recommendation for inter-vention at these levels of systolic pressure in theelderly population at large, particularly when there iscoexistent disease. Patients with severe posturalhypotension should not receive blood pressurelowering drugs.

Isolated systolic hypertension in younger patients isuncommon and there are no trial data on the potentialbenefits of treatment in such cases. By extrapolation,however, it seems reasonable to recommend that a

threshold pressure of 160 mm Hg systolic should beconsidered an indication for treatment in youngerpatients, irrespective of the diastolic pressure (fig 2).

Treatment goalsIt remains an issue ofmuch concem that around half

of treated hypertensive patients do not achieve accept-able blood pressure control. In trials reported to datethe benefits of treatment refer to the blood pressuresachieved in those trials.' Diastolic pressure should bereduced to less than 90 mm Hg but there is no hardinformation to provide guidelines on target levels forsystolic pressure. In the absence of such data a pressureof less than 160 mm Hg seems prudent. Some workershave suggested lower target pressures, such as less than85 mm Hg diastolic and less than 125 mm Hg systolic,'8but there is concem that overaggressive reduction indiastolic pressure may lead to an increase in coronaryevents in patients with established ischaemic heartdisease.'9-2' We believe that the evidence is insufficientto recommend a limit on blood pressure reduction.Nevertheless, in patients whose diastolic pressure hasbeen lowered to less than 80 mm Hg it seems sensibleto consider reducing treatment and in some cases

withdrawing it completely-so long as systolic pres-

sure is also well controlled and blood pressure isreviewed regularly for at least one year and treatment isreintroduced should blood pressure rise.

Drug treatment

Two classes of drugs have been adequately andextensively tested in long term prospective outcometrials: diuretics (particularly the thiazides) and iblockers. Some trials in elderly hypertensive patientsreport beneficial results with thiazide-potassiumsparing diuretic combinations. Newer classes of drugsmay be equally or even more effective in loweringblood pressure but have not been evaluated in longterm outcome trials. They include angiotensinconverting enzyme inhibitors, calcium channelblockers, and ot blockers. The Joint National Com-mittee on Detection, Evaluation, and Treatment ofHigh Blood Pressure in the United States and theWorld Health Organisation and Intemational Societyof Hypertension accept the inclusion of these newagents as altemative first line drugs.23

FIG 2-Thresholds for drug treatment of hypertension with reference tosystolic blood pressure 160mm Hg. *Repeated measurements

The first British Hypertension Society workingparty recommended that the newer classes of drugsshould be considered as "altemative" first line agentswhen diuretics and ,B blockers are contraindicated orineffective or when side effects occur. The secondworking party reaffirmed this view. The committeewas, however, divided on the question of prescribingnewer drugs instead of diuretics and ,B blockers as firstline treatment when these were not contraindicated.This difference of opinion was also recorded in a recentsurvey of the membership of the British HypertensionSociety. Few doubt the hypotensive efficacy of thesenew drugs and all recognise their role in selectedconditions such as diabetes, asthma, heart failure, andgout or when the traditional first line drugs are poorlytolerated and there is impaired quality of life. The

BMJ VOLUME 306 10 APRIL 1993

Drug treatment* Diuretics

* 3 blockers* Calcium entry blockers* Converting enzyme inhibitors* ot blockers

985

on 22 October 2020 by guest. P

rotected by copyright.http://w

ww

.bmj.com

/B

MJ: first published as 10.1136/bm

j.306.6883.983 on 10 April 1993. D

ownloaded from

choice of diuretics and c blockers as preferred drugs inpatients with dyslipidaemia is controversial.22The main concern expressed by the second working

party was the absence of long term data on morbidityand mortality with the newer agents. The workingparty recommended that a definitive outcome trialshould be undertaken, and one is currently beingplanned. Meanwhile, doctors will probably continue todiffer in their views and practice.Recommendations for the selection of drugs in

particular patients are listed in table I. Table IIsummarises the more common side effects. Quality oflife during treatment of hypertension has been assessedin various studies and is well maintained with many ofthe drugs currently in common use2324When all clinical factors are equal individual drug

costs should be taken into consideration, particularlyin view of the substantially lower cost of diuretics. Forelderly hypertensive patients evidence from the MRCtrial suggests that thiazide diuretics combined with apotassium sparing drug may be the preferred first linetreatment,6 although broadly similar benefits were seenin the SHEP study when chlorthalidone was usedalone.4

Factors affecting selection ofdrugs* Presence or absence of contraindications* Side effects* Coexisting disease

DosageWhichever agents are chosen as first line drugs

treatment should begin at the lowest recommendeddose. If the first drug is ineffective but well toleratedthe dose may be increased. In mild hypertension it isusually better to change to another agent rather thanadd an additional drug. If the first drug is only partiallyeffective, then adding a second drug from anotherpharmacological class is indicated. Drug combinations

TABLE I-Checklist of limitations on use of hypotensive drugs in patients with second condition. (Drugs notlisted in ranking order)

Angiotensinconverting

13 enzyme Calcium alCoexisting disease Diuretic blocker inhibitor antagonist blocker

Diabetes Care needed* Care neededt Yes Yes YesGout No Yes Yes Yes YesDyslipidaemia Controversial§ Controversial§ Yes Yes YesIschaemic heart disease Yes Yes Yes Yes YesHeart failure Yes No Yes Care neededt YesAsthma Yes No Yes Yes YesPeripheral vascular disease Yes Care neededt Care needed* Yes YesRenal artery stenosis Yes Yes No Yes Yes

*Diuretics may exacerbate diabetes.t,B blockers should be used with care in diabetes because awareness of insulin hypoglycaemia may be dulled. In non-insulin dependent disease 1 blockers may worsen glucose tolerance and exacerbate the deranged lipid profile.tCare needed when using calcium antagonists, particularly verapamil and diltiazem, in heart failure and when usingangiotensin converting enzymes inhibitors and 13 blockers in peripheral vascular disease because of an associationwith renal artery stenosis, a condition in which extreme care should be taken.SChoice of 13 blockers and diuretics in patients with dyslipidaemia is controversial.22

TABLE 1i-Checklist of known and common or important side effects with different classes of drug. (Sideeffects not listed in ranking orderfor different classes ofdrugs)

Angiotensinconverting

,B enzyme Calcium alsCommon side effects Diuretic blocker inhibitor antagonist blocker

Headache - - +Flushing - - +Dyspnoea - + -

Lethargy - + - - -

Impotence + + - -

Cough + - -Gout + - -Oedema +Postural hypotension + - - +Cold hands and feet - +

may be required in up to half of the cases. Combina-tions should be selected rationally and choice based onthree principles: drugs acting on different physio-logical systems have complementary action; reflexresponses to a single agent may be counteracted by asecond drug; and suboptimal doses of two agents mayavoid side effects of higher doses of a single drug.Examples of logical combinations are diuretics and iblocker; angiotensin converting enzyme inhibitor anddiuretic; dihydropyridine calcium entry blocker and Piblocker, angiotensin converting enzyme inhibitor andcalcium entry blocker; a blocker and ,B blocker.

Patient investigationEssential tests needed on all patients with hyperten-

sion are urine analysis (Dipstix) and measurement ofserum electrolyte and urea or creatinine concentra-tions. It is highly desirable to obtain an electrocardio-gram (for evidence of myocardial ischaemia or leftventricular hypertrophy) and measure blood glucoseand serum lipid values. A full blood count is useful as araised haemoglobin concentration is a risk factor forstroke and its measurement will detect patients withpolycythaemia. A raised mean corpuscular volumesuggests a high alcohol intake. In patients withborderline hypertension and abnormal electrocardio-gram the question of possible target organ damage maybe answered by echocardiography, which is a moresensitive determinant of left ventricular hypertrophy.A chest radiograph may help in older patients (largeheart, heart failure) or when clinically indicated.

Referrals for specialist adviceAny patient found to have malignant or accelerated

phase hypertension should be referred to hospital asan emergency case. Patients suspected as havingsecondary hypertension-for example, those withhypokalaemia or proteinuria and those with renalimpairment-should also be referred for specialistadvice. Other groups who should be referred arepatients with refractory hypertension or hypertensionthat is difficult to treat-for example, when two ormore drugs have failed to control blood pressure;patients whose hypertension shows wide fluctuations,is of recent or sudden onset, or which is worseningdespite treatment; and hypertensive patients agedunder 35 or who have multiple cardiovascular riskfactors-for example, hypertension, diabetes, andhyperlipidaemia.

Additional issues* Consider referral for specialist advice* Drug withdrawal possible in some cases

* Regular follow up necessary

Follow upFrequency of follow up depends on the severity of

the hypertension, the stability and degree of bloodpressure control, patient compliance with drug treat-ment, and the need for non-pharmacological advice.Initially, frequent visits may be required to assessbaseline blood pressure. When treatment is initiatedand blood pressure stabilised three monthly measure-ments of blood pressure should be sufficient in mostcases. In primary health care and in hospital bloodpressure clinics nurses have a particularly importantrole, not only for careful measurement of bloodpressure and the possible reduction of the "white coat"effect but also in counselling the patients, providing

BMJ VOLUME 306 10 APRIL 1993986

on 22 October 2020 by guest. P

rotected by copyright.http://w

ww

.bmj.com

/B

MJ: first published as 10.1136/bm

j.306.6883.983 on 10 April 1993. D

ownloaded from

non-pharmacological advice, and assessing the sideeffects of drugs.

Ambulatory blood pressure monitoringThe role of 24 hour ambulatory blood pressure

monitoring is being evaluated.25 At present it has littleplace in routine management, largely because of costsand the absence of long term prognostic data. It is usedin specialist centres in the assessment of borderlinehypertension and "white coat" hypertension.2627

Stopping treatmentPatients (usually with mild hypertension) whose

blood pressure is consistently within the target rangeand in whom there is no evidence of target organdamage may have their doses of antihypertensivedrugs reduced with careful monitoring. In somepatients drug treatment may be withdrawn. Non-pharmacological measures should be continuedindefinitely. Subsequent regular long term bloodpressure monitoring is mandatory.

I Swales JD, Ramsay LE, Coope JR, Pocock SJ, Robertson JIS, Sever PS, et al.Treating mild hypertension. BMJ 1989;298:694-8.

2 Joint National Committee. 1988 Report of the JNC on detection, evaluationand treatment of high blood pressure. Arch Intern Med 1988;148:1023-38.

3 Guidelines Sub-Committee. 1989 Guidelines for the management of mildhypertension: memorandum from a WHO/ISH meeting. J Hypertension1989;7:689-93.

4 SHEP Cooperative Research Group. Prevention of stroke by antihypertensivedrug treatment in older persons with isolated systolic hypertension. AAMA1991;265:255-64.

5 Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO.Morbidity and mortality in the Swedish trial in old patients with hyperten-sion (STOP-hypertension). Lancet 1991;338:1281-5.

6 Medical Research Council Working Party. MRC trial of treatment ofhypertension in older adults: principal results. BMJ 1992;304:405-12.

7 Petrie JC, O'Brien ET, Littler WA, de Swiet M, Padfield PL, Dillon MJ.British Hypertension Society recommendations on blood pressure measure-ment. BM7 1986;293:611-5.

8 Treatment of Mild Hypertension Research Group. The treatment of mildhypertension study: a randomised, placebo-controlled trial of nutritional-

hygienic regimen along with various drug monotherapies. Arch Intern Med1991;151:1413-23.

9 Medical Research Council Working Party. MRC trial of treatment of mildhypertension: principal results. BMJ 1985;291:97-104.

10 Hamilton M, Thompson EN, Wiesniewski TKM. The role of blood pressurecontrol in preventing complications of hypertension. Lancet 1964;i:235-8.

11 Veterans Administration Cooperative Study Group on AntihypertensiveAgents. Effects of treatment on morbidity in hypertension; results inpatients with diastolic blood pressure averaging 115 through 129 mm Hg.JAMA 1967;202:1028-34.

12 Veterans Administration Cooperative Study Group on AntihypertensiveAgents. Effects of treatment on morbidity in hypertension. II. Results ofpatients with diastolic blood pressure averaging 90 through 114 mm Hg.JAMA 1970;213:1143-51.

13 Stamler J, Neaton JD, Wentworth DN. Blood pressure (systolic and diastolic)and risk of fatal coronary heart disease. Hypertension 1989;13(suppl 1):2-12.

14 MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, et al. Bloodpressure, stroke and coronary heart disease. Part 1. Prolonged differences inblood pressure: prospective observational studies corrected for the regres-sion dilution bias. Lancet 1990;335:765-74.

15 British Hyperlipidaemia Research Association. Detection and management ofblood lipid disorders. Current Science. London: 1990:5-8.

16 British Hyperlipidaemia Research Association. Strategies for reducingcoronary heart disease and desirable limits for blood lipid concentrations:guidelines of the British Hyperlipidaemia Association. BMJ 1987;295:1245-6.

17 Taskforce on Prevention of Coronary Heart Disease. Scientific backgroundand new clinical guidelines. Nutrition, Metabolism and CardiovascularDiseases 1992;2:1 13-54.

18 Fletcher AE, Bulpitt CJ. How far should blood pressure be lowered? N EnglJMed 1992;326:251-4.

19 Cruickshank JM, Thorpe JM, Zacharias FJ. Benefits and potential harm oflowering high blood pressure. Lancet 1987;i:581-4.

20 Fletcher A, Beevers DG, Bulpitt CJ, Butler A, Coles EC, Hunt D. Therelationship between a low treated blood pressure and IHD mortality. Areport from the DHSS hypertension care computing project (DHCCP).3 Hum Hypertens 1988;2:1 1-5.

21 Cruickshank JM. Coronary flow reserve and the J-curve relation betweendiastolic blood pressure and myocardial infarction. BMJ 1988;297:1227-30.

22 Rosman J, Weidmann P, Ferrari P. Antihypertensive drugs and serumlipoproteins.Journal ofDrug Development 1990;3(suppl 1): 129-39.

23 Fletcher AE, Bulpitt CJ, Chase DM, Collins WCJ, Furberg CD, Goggin TK,et al. Quality of life with three antihypertensive treatments-cilazapril,atenolol, nifedipine. Hypertension 1993;19:499-507.

24 Hjemadahl P, Wiklund IK. Quality of life on antihypertensive therapy.Scientific end-point or marketing exercise?J Hypertension 1992;10: 1437-46.

25 Pickering TG, O'Brien E. Second intemational consensus meeting on 24 hourambulatory blood pressure measurement: consensus and conclusions.J Hypertension 1991 ;9(suppl 8):S2-6.

26 Pickering TG. Can ambulatory blood pressure monitoring improve thediagnosis of mild hypertension?J Hypertension 1990;8(suppl 6):S43-7.

27 O'Brien E, Cox J, O'Malley K. The role of 24 hour ambulatory blood pressuremeasurement in clinical practice. IHypertension 199 1;9(suppl 8):S63-5.

(Accepted 28J7anuary 1993)

Is the money following the clients with learning disabilities?

Gyles R Glover, Jenifer Rohde, Richard D T Farmer

Academic Department ofPublic Health andEpidemiology, CharingCross and WestminterMedical School, LondonSWlP 2ARGyles R Glover, seniorlecturerJenifer Rohde, registerorganiserRichard D T Farmer,professor

Correspondence to:Dr Glover.

BMJ 1993;306:987-90

For the past decade patients with learning disabilitiesliving in long stay mental handicap hospitals havebeen resettled in the community. Local authoritieshave also taken on the care of new patients whowould once have been long stay residents. Theimperfect data that are available suggest that inEngland about half the residents in mental handicaphospitals in 1981 are now the responsibility of localauthorities; the figures for Wales and NorthernIreland are 38% and 330/0. Data on revenue suggestthat the savings to the health service are much less-perhaps 90/o in Northern Ireland and 3.6% inEngland, although there have also been capital gainsthrough the sale of hospitals. Existing methods oftransferring money from health to local authorities-joint finance and "dowries" for individual patients-do not seem adequately to have compensated localauthorities. Moreover, as patients still to be trans-ferred are more severely disabled local authoritieswill require larger sums-about £26 000 per patientper year plus £39 200 in capital. If the governmentchooses not to transfer these resources from healthauthorities it will be switching funds away fromlearning disabled people to other care groups.

Department of Health figures show that over the pastdecade the number of residents of hospitals for people

with learning disabilities has substantially declined.This reflects a progressive transfer of responsibility forthe care of these people from health authorities to localauthority social services departments. This transferhas been government policy since 1959.1 Desirable assuch a transfer might be, if it is to work the money forthe care of these clients needs to follow them. We lookhere at some new information about how much of theburden of care has shifted in the past decade and howmuch of the funding has followed.Two new sources of information have become

available. Detailed evidence about the City of West-minster and the Royal Borough of Kensington andChelsea has been collated by the academic departmentof public health and epidemiology at Charing Crossand Westminster Medical School, where two of us(RDTF and JR) have recently studied the register ofthe learning disabled people of the two boroughscovering the past eight years. National data comefrom responses to a series of written questions to thefour secretaries of state with responsibility for theBritish health service, put down in the last weeks of theold parliament by the then Liberal democrat healthspokesperson, Charles Kennedy MP.2The information is incomplete and comes in an

imperfect format, and we have had to make severalassumptions in analysing it. Nevertheless, in view of

BMJ VOLUME 306 10 APRIL 1993 987

on 22 October 2020 by guest. P

rotected by copyright.http://w

ww

.bmj.com

/B

MJ: first published as 10.1136/bm

j.306.6883.983 on 10 April 1993. D

ownloaded from