28 June 2022

Blood pressure checks are carried out by our Patient and Public Involvement Team and volunteer Heart Heroes in community settings.

Health and care systems and providers across the UK, can now take advantage of the first primary care national blueprint, written by the Cheshire and Merseyside Health and Care Partnership’s Digital First Primary Care team and based on work involving the Innovation Agency.

The blueprint captures our learning from the rollout of the national programme ‘BP@Home’ which has distributed more than 200,000 blood pressure monitors to people who have been diagnosed with uncontrolled high blood pressure (hypertension).

Blueprints highlight important ingredients needed for sustainable health system improvements, including step-by-step guides for organisations to enable them to carry out digital transformation more quickly and cost effectively than in the past.

Cheshire and Merseyside is one of the first integrated care systems to test this approach, to help to reduce the number of deaths caused by heart attacks and strokes.

It provides step by step guides and shares learning from the local rollout of the programme, that can then be tailored by other healthcare systems and providers to suit their own local needs and requirements. This includes how the local programme used digital enablers to empower patients across Cheshire and Merseyside to monitor their blood pressure levels and submit readings electronically to their GP from the comfort of their own homes.

The blueprint provides examples of the support that was provided to clinicians, to enable them to determine which patients to approach, using a locally developed blood pressure quality improvement or BPQI tool, co-developed by the Innovation Agency and British Heart Foundation in partnership with places and practice staff.

The blueprint is significant because it is the first of its kind aimed at supporting improvements in primary care settings, such general practices and community pharmacies. 

As well as supporting the rollout of BP@Home across the country, it is hoped that the approach can be replicated to support other digital programmes of work in primary care settings. This includes using ‘remote monitoring’, the process of using technology to enable patients to monitor health parameters such as blood pressure and blood sugar levels, peak expiratory flow, and pulse oximetry, while alerting clinicians to any deterioration in their condition.

Sally Deacon, Programme Lead for the Hypertension Accelerator Project, part of the Cheshire and Merseyside Health and Care Partnership’s Digital First Primary Care programme, said: “High blood pressure is a common condition that can cause cardiovascular disease, heart attacks and strokes, and many cases of dementia, if it’s not detected and monitored appropriately.

“Improving how we monitor blood pressure presents one of the biggest opportunities to save lives, minimise the burden of disease for patients, and reduce inequalities, and that’s why my team and I are so passionate about capturing and sharing our learning from our work here in Cheshire and Merseyside.

“We recognise that as well as being used to improve outcomes for patients that may suffer from hypertension, there is also significant opportunity for the blueprint to be used by other healthcare systems and providers across the country, to improve the detection and management of long-term conditions in general.”

The blueprint, Hypertension: Digital Enablers Supporting Home Blood Pressure Monitoring in General Practice, is available to members of the Future NHS workspace; colleagues not already registered on the workspace and who would like access can email

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