Exeter Collaboration for Academic Primary Care (APEx) Blog
Exeter Collaboration for Academic Primary Care (APEx) Blog
Posted by ma403
5 November 2025
Caring for people with long-term conditions takes up substantial resources. This isn’t news, but it’s surprising how much we still don’t know. It’s often simple stuff, that would really help us deliver care more effectively and efficiently. Work being undertaken by APEx academics in our Long-Term Conditions research theme is looking at some of these important unknowns.
Take postural hypotension, for example – an abnormal drop in blood pressure on standing, which can be associated with serious consequences such as falls. Postural hypotension has been estimated to affect one-fifth of older adults. However, we are very poor at recognising when to test for it and infrequently record the diagnosis in primary care.1,2 Most clinicians will recognise dizziness on standing as a symptom suggesting postural hypotension is present. But there are also a range of other symptoms of the condition that are under-recognised, and so don’t trigger postural testing by clinicians. In addition, many people have recognised risk factors for postural hypotension without symptoms – they tend to miss out on testing as well.
Postural hypotension commonly co-exists with hypertension. It’s worse with uncontrolled hypertension but intensive blood pressure lowering brings more postural symptoms and increased falls. Antihypertensives are associated with postural hypotension so stopping them feels a logical treatment. Small, often post-hoc, studies of deprescribing give unclear and conflicting results. We lack definitive trial evidence, in populations representative of our patients, to help us choose between tight blood pressure control and postural symptom control.3 NICE advises us to manage hypertension using standing blood pressure readings where there is postural hypotension, but here in APEx we’ve found negligible evidence to link standing blood pressure control with cardiovascular risk reduction4. We just don’t know what we are doing!
Another important aspect of long-term care is ensuring the safe and effective use of medications. Around £10 billion is spent on medications in primary care each year, with twice as many prescriptions issued now compared to 30 years ago. Clearly, medications have revolutionised health and well-being for millions of people. However, medications can also cause important harms and place a burden on patients and health services alike, and a government report in 2021 suggested that 10% of all prescriptions might be inappropriate.5
Sorting that out seems a no-brainer – but how? Structured medication reviews were rolled out in recent years as a means of tackling inappropriate medication use and improving the safety and effectiveness of prescriptions. This has been supported by a substantial growth in GP-based clinical pharmacists. Yet the evidence supporting such reviews, and the way in which pharmacists are employed to tackle the issue, is lacking.6 A major clinical trial (IMPPP) that we helped lead found that even when you conduct medication reviews in a very carefully structured way, together with the combined expertise of both GPs and pharmacists working together, and some additional “bells and whistles” to enhance clinicians’ engagement with the whole process, medication safety doesn’t improve7. Another example of how policy and practice is not backed up by science.
We live in a world of increasingly protocolised medicine – one driven by clinical guidelines and strict policy edicts, and one where clinicians feel compelled to “follow the recommendations”. Too often, we forget that these are not always underpinned by hard evidence. Researchers in APEx are working to try to address some of these important gaps in clinical knowledge around long-term conditions. But in addition, we are helping to understand the uncertainty that results from such knowledge gaps, and to develop better approaches to shared decision-making which can be applied in such circumstances. Whether it be the management of postural hypotension, optimising long-term medicines, or one of many other important issues in primary care, this research will help clinicians and patients to deal with the unknowns together.
Chris Clark and Rupert Payne
