Digitally enabling blood pressure monitoring at home

Digitally enabling blood pressure monitoring at home

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We helped the Cheshire and Merseyside Integrated Care System increase patients measuring their blood pressure at home, delivering a major digital transformation within primary care which became the first national digital-first blueprint.


The most recent Quality and Outcomes Framework (QOF) figures (2020/21) show that throughout the pandemic there has been a 22% reduction nationally in the proportion of people on the hypertension register who have been recorded as ‘treated to target’.

In Cheshire and Merseyside the reduction is more pronounced. The reduction across all ages has been from 70.1% (2019/20) to 44.8% (2020/21), a fall of 25.3%.

Liverpool, Cheshire and Wirral were funded by the Digital First Primary Care national programme to become ‘Hypertension Accelerator’ sites. This included 229 GPs covering over 1million people. In collaboration with the ‘BP@home’ programme, which helps people with home monitoring for high blood pressure (BP), they tested approaches and digital tools to enable remote management of hypertension patients in primary care. The aim was to inform the approach for at-home / remote BP monitoring to become business as usual for GPs across the Cheshire and Merseyside Integrated Care System (ICS).


We deployed a senior programme consultant to develop the collaboration between primary care teams, digital providers, Innovation Agency NWC (the Academic Health Science Network for the North West Coast) and MLCSU technology and procurement experts. The goal was to implement a digital solution for primary care to deliver BP readings at home, with a combination of elements:

  • Ability for texting between GPs and patients and forms for patients to submit BP readings
  • GP systems applying approved clinical terminology (‘SNOMED’ codes)
  • GP based Blood Pressure Quality Improvement (BPQI) tool offering:
    • EMIS-embedded dashboard and audit tool (aligned to National Institute of Clinical Excellence (NICE) guidance) to support patient list risk stratification and identify cohorts for further management
    • EMIS-embedded consultation templates (for new and existing patients)
    • Practice protocols, printable patient information leaflets and training support
  • Clinical Decision Support Tool (‘Ardens’), aligned to NICE guidance, to give clinicians easy access to best practice resources.
  • Sharing knowledge of the first Digital Accelerator Blueprint across all NHS health systems by providing step by step guides and learning from the local rollout via the NHS England and Improvement Blueprint Futures platform.


Within the first three months of deployment approximately 50% of GPs downloaded the BPQI tool.

There has been a more than 300% increase in the number of patients within Liverpool, Cheshire and Wirral submitting their BP readings remotely via text and over 60 practices so far using patient digital submission tools for BP readings.

These figures are likely to increase as more GPs come onboard this ongoing project.

“MLCSU have delivered an excellent  collaboration across our system using digital enablers to empower patients across Cheshire and Merseyside to monitor their blood pressure levels and submit readings electronically to their GP in the comfort of their own homes, providing the first Digital Accelerator Blueprint to share learning, supporting rapid scaling and adoption of remote monitoring.”

Alex Chaplin, Head of Digital, Cheshire & Merseyside ICS

“MLCSU resource has consistently impressed, with her skills in building a community of practice and commitment to this project, bringing a range of stakeholders and MLCSU expertise together across a wide region and instilling a genuine momentum to the ongoing progress of the project.”

Mike Purdie, IT Service Delivery Lead, Cheshire CCG

“MLCSU plays an integral role supporting the programme with a pragmatic and flexible approach. As a result, we have high engagement from stakeholders. For us, there has been good groundwork set for strengthening our approaches to BP and achieving our objectives.”

Dr Julia Reynolds, Associate Director of Transformation, Innovation Agency NWC

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