Enabling scale and spread of technology-enabled remote monitoring of blood pressure at home: findings from a rapid qualitative evaluation

Context: a growing focus on innovative approaches to managing hypertension in policy and practice

Hypertension is an important public health issue given its prevalence and links to the risks of cardiovascular disease (CVD). According to Public Health England (PHE), 11.8 million adults aged 16 years or older in England have hypertension, approximately 26.2% of the adult population. PHE estimates that for every ten people diagnosed with hypertension, another seven are undiagnosed and untreated.¹ Hypertension is a primary risk factor for several CVDs such as coronary artery disease, congestive heart failure, and atrial fibrillation,² and is considered by the World Health Organisation (WHO) as one of the most preventable causes of premature death.³ There is compelling evidence for the benefits of controlled blood pressure (BP) on CVD outcomes,^4–6 though several studies suggest that adequately controlling BP is challenging.^7–9 A 2021 UK-based study found that only two in five adults between ages 40 and 69 on hypertension treatment have their BP adequately controlled.⁸

National initiatives in the United Kingdom (UK) have long sought innovative approaches to support patients with hypertension,^10–13 including to improve BP control and cardiovascular outcomes. Examples include the national BP Optimization Programme (now completed, but which focused on managing hypertension in primary care) and the ongoing Cardiovascular Disease Prevention (CVDPREVENT) audit to support quality improvement in general practice, which started in 2019/2020.^14,15 As part of the growing interest in innovative approaches for managing hypertension, policymakers, commissioners, and healthcare providers have also focused on the potential to use technology. This reflects a wider interest in technology-enabled care across different clinical conditions, to improve healthcare access, efficiency and effectiveness and to help address growing demands for care and workforce capacity constraints.¹⁶ Some hypertension-focused programmes specifically look to use technology to enable remote monitoring of BP in home settings. These included the 2020 BP@home program, which provided BP monitors to NHS organizations in England¹⁷; the 2015/2016 Scale-Up BP program, which focused on implementing TERM BP in Scotland¹⁸; Connect Me program in Scotland,¹⁹ which involves multiple remote monitoring pathways, including TERM BP. In England, local and regional health system decision-makers at the practice, primary care network (PCN), integrated care board (ICB), and integrated care system (ICS) levels have implemented remote monitoring programs for BP.^10,12,20

In this context, the Digitally Enabled Care in Diverse Environments (DECIDE) centre for rapid evaluation of technology-enabled remote monitoring evaluated the implementation of technology-enabled remote monitoring (TERM) of blood pressure (BP). The overarching aim of the evaluation was to improve the evidence based on what works, how, why, and in which contexts. The evaluation is nested in wider efforts to provide timely, practical learning that can help health system decision makers at the national, regional, and local levels make informed decisions about how to implement, sustain, spread, and scale remote care pathways. The intended government shifts in healthcare – from hospitals to communities, sickness to prevention, and analogue to digital care – underline the need for such evidence and learning to support changes health service transformation, including in relation to major public health challenges such as hypertension.

Key insights and gaps in the literature on blood pressure home monitoring, including TERM BP

We conducted a rapid scoping review of the literature on BP remote monitoring, focusing on the UK context, to help scope the context and focus our evaluation. 18 papers from peer-reviewed literature and 12 papers from grey literature were included in the review. Full details of the methods and findings from the literature review are available in the Open Science Framework data repository.²¹

Blood pressure monitoring always requires a blood pressure measurement device, such as an upper arm blood pressure machine. Remote monitoring, also known as ‘home BP monitoring’ or ‘self-monitoring’ therefore always relies on some form of technology, but the level of technology-enablement can vary. For example, paper-based BP remote monitoring includes patients using a BP monitor to take readings and communicate readings to a healthcare professional (HCP) in person or through email, phone call, or post. In remote monitoring of BP involving higher levels of technology-enablement (hereafter referred to as technology-enabled remote monitoring), patients use a BP monitor to take the readings and then communicate readings back to a healthcare professional via a weblink that patients access through an SMS message, or through a mobile application.^22,23 ‘Technology-enabled’ remote monitoring of BP relies on the health service using a data platform and communications technology to request patients to take BP measurements and for patients to share blood pressure measurements with healthcare staff. Monitors and related equipment (such as BP cuffs) are also considered a part of the technology.

BP remote monitoring (paper-based and technology-enabled) has been found in randomized controlled trials to be effective in efforts to help improve BP control in patients with hypertension,^11,13,24,25 including high-risk individuals with existing CVD, diabetes, or chronic kidney disease.²⁶ Compared to usual care, both paper-based and TERM BP approaches were found to be helpful in efforts to effectively control BP.²⁴ While there is limited evidence on the extent of BP remote monitoring, a study of 11 million patients in the UK found that, in 2016/2017, only 25.6% of those diagnosed with hypertension had a record of home or ambulatory blood pressure monitoring prior to their diagnosis.²⁷

Despite compelling evidence on clinical outcomes (namely BP control), evidence on the impacts of BP remote monitoring on health service utilization is inconclusive^28,29 and on cost-effectiveness is mixed.^30–32 Existing evidence points to considerable variation in the implementation of care pathways involving TERM BP, but provides limited detail on the nature of care pathways and implementation processes and links to impacts on health services.^12,23,33 There are significant evidence gaps related to understanding which types of remote monitoring BP (paper-based, technology-enabled) approaches can support improved patient outcomes and service impacts in specific contexts, how, and why. Thus, while the evidence in support of BP remote monitoring is strong, there is less understanding of the specific impact of technology enablement and TERM BP services and there may be scope to improve overall adoption.

Research aim and questions

Our evaluation studied the implementation of TERM BP. Our core research question was: How can interventions focused on the remote monitoring of blood pressure be designed, implemented, spread, scaled, and sustained to optimize patient outcomes and impacts on health services in the United Kingdom (UK)? The following sub-questions guided the evaluation.

We conceptualize spread as entailing efforts to transfer successful interventions beyond the original adoption context (e.g., from one general practice to another), scale-up as establishing an infrastructure that can support widespread adoption (e.g., to new patients in the same PCN), and sustainability as maintaining an intervention (in its original or adapted form) over time.³⁴

Evaluation design and approach

We conducted a multi-method rapid evaluation involving qualitative data collection initially via a series of scoping interviews and then across four primary care sites that had implemented TERM for BP. Qualitative data collection included a document review, interviews with service delivery staff and patients, and site visits to each of the four sites. Subsequent multi-stakeholder workshops with site staff, a wider range of patients engaged with TERM BP, and regional and national stakeholders helped refine learning. The rapid evaluation approach included regular communications with NHS England (specifically the BP@Home team, part of NHS@Home) to understand current policy influences and share timely feedback. The evaluation forms part of a 3-year programme of work by DECIDE, funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research (HSDR) program.

Conceptual Framework. This theory-driven evaluation was sensitized by a sociotechnical systems perspective³⁵ and the NASSS (Non-adoption, Abandonment, and Challenges to Scale-up, Spread, and Sustainability) framework.^34,36 The NASSS framework ( Figure 1) acted as a primary sensitizing device to understand the various factors that affect implementation, spread, and scale, and as an analytical tool to help us understand and explain the complexity involved in TERM BP service delivery over time. The NASSS framework includes seven domains: (i) the nature of the health condition (including both physical and sociocultural factors); (ii) technology type (including both material/physical properties and associated knowledge needed for it to work, supply models, and commercial/intellectual propoerty considerations); (iii) the value proposition (for developers, patients, health service); (iv) the role of adopters (e.g., healthcare staff, system decisionmakers, patients, and carers); (v) organizational and wider support (capacity for innovation, support structures, and processes framing innovation decisions and implementation and monitoring over time); (vi) the wider system (e.g., sociocultural, political, regulatory); and (vii) potential for adaptation over time.

Figure 1. The NASSS framework (Non-adoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability) to understand the various factors that affect implementation, spread and scale.³⁷

This framework informed the development of the interview guide and sensitized our analytical approach. Insights from our scoping interviews and wider work of DECIDE led us to adapt NASSS domain categories related to influences on implementation (i.e., technology, adopters, organizations, wider system) into four domains to inform accessible communications with evaluation participants. The adapted domains are technology and supplier, health and care system, provider organizations and workforce, and patients. The NASSS domain of embedding and adaptation is cross-cutting and applied across these four domains.

Evaluation methods

The evaluation was conducted in three phases. Phase 1 involved scoping interviews. Phase 2 involved a document review, staff and patient interviews, and site visits. Phase 3 involved a series of online workshops, bringing together four primary care sites that had implemented TERM BP, a wider set of patients, and regional and national decision makers.

Phase 1: Scoping interviews (January to February 2024)

We conducted 30 scoping interviews to understand the landscape of TERM BP in the UK, refine the evaluation questions, and inform primary care site sampling (see below). We initially sought a purposive, maximum-variation sample of interviewees via DECIDE’s governance structure and wider networks. We then broadened this using a snowballing approach. This enabled diversity in research, clinical, and Patient and Public Involvement and Engagement (PPIE) expertise, as well as those involved in policy and decision-making at the national, regional, and local levels (e.g., leads from integrated care boards, Health Innovation Networks, and general practices).

Phase 2: Qualitative evaluation of four primary care sites (March 2024 to March 2025)

The qualitative evaluation of four primary care sites implementing TERM BP focused on understanding implementation processes and the complexity of TERM BP as a service intervention, and on exploring diverse influences on implementation, spread, and scale. We sought a purposive sample of sites that had implemented TERM BP for some time to enable us to learn about implementation processes and inform considerations for spread and scale. We sought diversity in site geography, technology used, and workforce models to support the implementation of the TERM BP ( Table 1). We use pseudonyms for the sites and technologies.

See the Data Availability section for access to information for the full analysis of the findings at each site.

Document review

We undertook a focused document review of TERM BP service planning or operational documents (2–3 per site, e.g. service protocol) that primary care sites shared to help us understand the origins of the service, service set-up, implementation, staff involvement, and workflows for TERM BP.

Staff and patient interviews

Staff and patient interviews allowed us to explore the implementation context and influences shaping implementation and the evolution and adaptation of services over time. At each site, we identified a lead that provided contact information to staff who we sought to engage as participants. We aimed to sample staff across a range of roles involved in planning, design, and/or delivery service pathways for TERM BP, including clinical staff such as GPs, nurses, pharmacists, healthcare assistants and administrative staff such as receptionists. Where possible we included staff from the system-level [e.g. PCN, ICS/ICB, Health and Social Care Partnership (HSCP)]. Staff at each site supported the identification of patients for interviews, aiming to recruit patients with varying characteristics, such as age, ethnicity, and clinical condition(s). Across sites, we interviewed 35 staff members and 15 patients with additional staff and patients also participating in workshops ( Table 2).

Semi-structured interviews with staff included questions about the motivation and rationale for TERM BP, the nature of the service pathway and implementation processes, including influences on the pathways and adaptation over time, perceived impacts and unintended consequences, and information of relevance to spread and scale efforts. Semi-structured interviews with patients explored their experience of TERM BP, including overall perceptions of how it is working for them, the level of guidance and support received from the practice, and any improvements they would like to make to the service pathway.

All interviews were conducted with MS Teams or telephone calls, digitally recorded and transcribed with contemporaneous notes taken by interviewers (FW, JW, SMo, HT, SMa, and DM). Each interview was then summarised using dedicated Rapid Assessment Procedure (RAP) sheets.^38,39

Site visits

We conducted site visits at three sites, allowing us to gain a sense of the organizational context and setting, explore the physical areas surrounding the delivery of TERM BP, meet with and engage staff involved in designing and delivering the service, and share emerging findings. At the fourth site, we were unable to schedule a visit due to availability and instead spent additional time with the site lead over MS Teams to discuss the context and setting of the service, clarify questions, and share emerging findings.

Phase 3: Online workshops (February 2025 to March 2025)

Three online workshops were conducted towards the end of data collection to support cross-case analysis and triangulate and refine the findings. The first workshop involved healthcare professionals across primary care sites (n = 7). The second workshop involved patients from sites that participated in interviews, and additional patients and caregivers with lived experience of BP remote monitoring recruited through a University of Oxford PPIE mailing list (n = 22). The third workshop involved a wider range of stakeholders in the implementation, design, and spread of TERM BP, including policymakers, ICB staff, clinical staff, and non-clinical staff (practice managers and digital care coordinators). Stakeholders (n = 17) were identified via wider networks and with input from the BP@Home team, with the content of the workshop focused on refining policy recommendations for national and regional decision-makers related to the implementation, scale, and spread of TERM BP.

Analysis and synthesis

We drew together the document analysis and RAP sheets from each primary care site into a summary document using NASSS as a synthesizing device. We then conducted a thematic analysis under each adapted NASSS domain both within and across primary care sites. We held four online analysis workshops involving the research team to share emergent findings, summarize emerging themes, and identify themes related to spread and scale. Case studies were written as part of the analytic process (see Data Availability for access to full case studies). Alongside NASSS we drew on two theoretical perspectives to further explore the influences on the implementation, spread, and scale of TERM BP. This included dialectical perspectives^40–42 to help us understand the tensions at play in implementing TERM BP, and sociotechnical traditions in science, technology, and innovation studies, specifically the literature on sociotechnical regimes^43–46 to consider interactions between technology and health services evolution When making final inferences from our evaluation, this information was triangulated with insights from other case study information sources and the wider literature).

Ethics and governance

The Research Governance, Ethics, and Assurance team at the University of Oxford (sponsor) classified the project as a service evaluation, and thus did not require research ethics approval. All participants had the capacity to provide informed consent and were provided with a project information sheet and consent form detailing the study aims, design, contacts, and data privacy. The participants were informed that they had the right to withdraw from the study at any point The project advisory group comprised three individuals with clinical, research, and public involvement experiences with BP remote monitoring. The group met regularly to inform them of data collection materials, reflect on emerging findings, and inform them of the dissemination strategy. Wider input from the DECIDE Steering Committee⁴⁷ informed the evaluation design, conduct, and avenues for dissemination.

Patient and public involvement and engagement

The evaluation was shaped by the involvement of the patients and the public from the outset. Early discussions with two PPIE experts drawn from the wider DECIDE programme⁴⁷ informed the evaluation design, sampling, and conduct. A dedicated PPIE group, involving three people with lived experience of remote blood pressure monitoring, contributed to interview guide development, analysis, and design and participation in a workshop with patient voice representatives.

Key findings summary

We expand on these key findings below.

How is tech enabled remote monitoring of blood pressure implemented?

Across sites, care pathways for TERM BP tended to include three key stages: patient identification and awareness-raising, recruitment and onboarding, and ongoing monitoring and management ( Figure 2). Patient identification and awareness raising refer to activities used to identify patients who might benefit from BP remote monitoring and help make patients aware that these services exist. Recruitment and onboarding activities support patients to take up the service, such as support for registration, education on how to take BP measurements and how to share measurements with the healthcare team, information sharing on how the service works, how patients and HCPs will engage with the process, and any other support and communication prior to a patient taking and sending their first reading. Ongoing monitoring includes patients receiving requests to complete BP remote monitoring measurements on a user interface (e.g., SMS message or mobile application) and the use of a data platform and interface by healthcare staff to process and appropriately follow up on the results of BP measurements.

Figure 2. The remote monitoring of blood pressure pathway.

Motivations for TERM BP

The emergence of the COVID-19 pandemic was a catalyst for greater digitization of health services and provided an impetus for greater focus on TERM BP. While consideration of digitally enabled care existed before the pandemic, staff at two sites flagged that reduced social contact during the pandemic accelerated the recourse to more remote care approaches, so that practices could in some way monitor the health of their patients and utilize staff working from home.

As one GP shared:

Although the pandemic catalysed TERM BP implementation, several staff across all sites noted motivations to improve care quality in BP control and hypertension management, which were bolstered by Quality Outcomes Framework (QOF) targets for hypertension management [1] in England tied to payments to general practices. In Scotland, where QOF is not in use, decisionmakers implemented the program in alignment with Realistic Medicine⁴⁸ to improve patient empowerment and shared decision making. Other motivations across the sites included a desire to help staff work more efficiently and help patients engage more actively with their own health conditions. Post pandemic, the practice of remote monitoring has been attuned to wider policy initiatives to support health system transformation including the growing focus on more digitally-enabled care, greater attention to issues of equity in accessing care digitally, and growing patient acceptance of digital care.

There are both shared and distinct potential benefits from TERM BP for staff and patients.

The value proposition associated with TERM BP pathways had both shared and distinct elements across healthcare staff and patients. Staff saw potential value in facilitating more accurate diagnosis, improving access to care for patients with hypertension, and supporting hypertension and medicine management, including through educating patients about blood pressure and supporting them in managing their own health. Releasing time for face-to-face GP consultations for patients who cannot engage remotely, thereby targeting inequalities in access to care, was also seen as important.

As one healthcare assistant (HCA) commented:

Many of these issues were also important to patients, particularly improved access to care, understanding blood pressure and hypertension (thereby providing reassurance to some patients), and engagement with their health to support better hypertension management, including through behavioural change.

As illustrated by one patient:

However, a few staff members noted that not all patients were motivated by such potential benefits, particularly some younger adults who do not think they need to monitor their BP.

Patient eligibility

The eligible population for TERM BP evolved over time, in line with the resources and capacity to deliver the service. All sites began using TERM BP for the monitoring and management of patients diagnosed with hypertension, including medication adjustments, and have since expanded the service to include the diagnosis of patients without previously diagnosed hypertension. This included patients who had an out-of-range in-person reading when presenting to the health service for other reasons as well as patients who may benefit from remote monitoring due to long-term conditions or in light of prescribed medication.

At Mid-Town Practice and South Coast PCN, patients who wished to engage with their BP irrespective of a relevant health condition were also eligible. North Market Practice initially focused on patients who could not engage in in-person BP checks, either as a result of their work situations or specific health conditions which made it difficult to travel to the practice, but sites did not consider diverse types of inequalities during service design.

TERM BP governance

Across primary care sites, TERM BP was governed either at the practice or ICB level. In North Market Practice, Green Hills Practice, and Mid-Town Practice, all decision-making was made at the practice level, while at South Coast PCN, strategic decision making occured at the ICB level and TERM BP was delivered by the PCN, with some support for referrals or follow up from practices. A staff member at South Coast PCN flagged that the PCN-led model was seen as an efficient way to deliver TERM BP at scale, with technology selection and funding occurring at the ICB level and coordination and delivery through PCNs.

Across interviews, there was no evidence that one governance model was more effective than the other. The appropriateness of a practice-led governance model seemed to depend substantially on effective GP leadership and existing practice-level resources (staff capacity and technological skills) to enable new ways of working and effective team relations. Where TERM BP was governed at the ICB level and delivered by the PCN, some staff flagged that substantial effort from the ICB programme lead and other ICB staff were required to engage with and ensure program buy-in from GP partners at local practices. This was linked to variation in capacity constraints, uncertain long-term funding, unclear benefits, and reluctance to change established models of care and invest time in new pathways.

Workforce organisation

Across primary care sites, there were both programme leads, who initiated the effort, garnered support, and helped to set the strategic direction for TERM BP, as well as clinical leads, who were clinically responsible for patient care through the TERM BP service pathway ( Table 1). Although programme leadership varied from GP partners to practice managers to ICB staff, the workforce to deliver TERM BP looked similar across sites and utilized multi-professional teams. The ICB-led and PCN-delivered model required effective coordination between the PCN and staff from multiple practices, supported through a dedicated digital care coordinator at South Coast PCN. Most sites primarily engaged existing staff in pathway delivery rather than establishing new roles (other than the digital care coordinator at South Coast PCN), although over time, all practice-led sites brought on additional staff to deliver the service.

At all sites, most interviewed staff spoke of clinical responsibility for TERM BP shifting to non-GP clinicians, such as clinical pharmacists, nurses, and advanced care practitioners ( Table 1). Clinical leads were supported by different mixes of HCAs and various nursing roles including nurse associates, trainee nurses, and physician associates (see Table 1). At most sites (except for North Market Practice), the clinical lead was the first point of contact for clinical guidance for HCAs or nurse staff, prior to potential escalation with the patient’s GP or the duty doctor. At North Market Practice, HCAs facilitated communication between patients and their GPs (rather than engaging in patient care themselves), so the shift to non-GP roles was more limited.

The role of HCAs and nurse associates in TERM BP (aside from that at North Market Practice) expanded to involve a greater degree of patient care related to disease management for hypertension; for example follow-up required for out-of-range readings and managing and addressing incoming BP measurements, including how to account for an incomplete set of readings. Regarding the clinical background necessary to make clinical judgements, one nurse commented,

Clinical training (both formal and on-job learning) was provided to support clinical staff at all sites to deliver new responsibilities. Staff at Mid-Town Practice, Green Hills Practice, and South Coast PCN also received technical training and education (developed in house or from technology suppliers) and education on how to use remote monitoring data communication platforms. Some suppliers also established a WhatsApp chat support community, and a regular newsletter to support ongoing education. The training at the South Coast PCN was particularly extensive, as illustrated by an HCA:

TERM BP stages and implementation activities

The implementation of TERM BP service pathways across sites involved common stages of patient identification and awareness, recruitment and onboarding, and ongoing monitoring and management, with seemingly warranted variations in the implementation of these stages.

Table 3 provides a summary of the implementation activities across each core stage in the pathway, prior to expanding on the information in the narrative that follows. Supplemental Tables 1-3 (see Data availability section) provide further information by site and stage.

Patient identification and awareness raising

Patients were identified through multiple channels, both planned and opportunistic, across all the sites. Planned recruitment utilised a range of software and required differing levels of manual input. Some processes, such as at Green Hills Practice, were fully automated by the data platform to identify patients from the EHR and automatically request measurements using SMS messages. Other processes were more manual, for example at South Coast PCN, where searches utilized a population health tool, but enabled staff to select patient criteria, such as cardiovascular risk or deprivation index, to prioritize patients for outreach. Opportunistic identification at all sites happened during in-person appointments where a clinic reading was outside the normal range, as well as through health and wellbeing clinics run by PCN staff at South Coast PCN, and by community pharmacies associated with Mid-Town Practice and North market practice.

Raising awareness appeared to be limited and varied across the sites. Staff at the South Coast PCN and Green Hills Practice flagged that opportunistic in-person circumstances were an opportunity to talk to patients about TERM BP, which relied on in-the-moment decisions about when to raise the subject and with which patients. The South Coast PCN raised awareness of TERM BP through community events at GP surgeries and markets, and at North Market Practice, there was a local initiative to support BP checks at gyms.

Patient recruitment and onboarding

Patient recruitment was done by clinical staff at all sites, including GPs, nurses, and HCAs, which could naturally follow in-person identification channels. Responsibilities for patient onboarding shifted away from GPs, and typically sat with HCAs or administrative staff. Patient onboarding was relatively informal in terms of not having written guidance for staff to use (only Green Hills Practice had a set of structured onboarding instructions for staff ) and generally involved providing instructions on how to input readings on a platform (whether through mobile app registration or engaging with the data platform via an SMS link), the technique of taking a BP reading using BP monitors, the duration and frequency of measurement, what to do if patients needed help, and, at Green Hills Practice, monitor provision to patients.

In-person support was complemented by online instructions linked to the TERM BP technology platform and user interface or additional email information on the importance of BP monitoring, how to use the platform, and how to take BP readings. Staff at all sites noted that patients who struggle with technology were able to contact support staff, but only in Mid-Town Practice offered a bespoke pathway for patients who may require additional support, such as patients with learning disabilities or severe mental illness.

Loaning of monitors was dependent on availability and sometimes involved prioritising patients who could not afford their own monitors. It was initially offered by both Green Hills Practice and North Market Practice during the patient onboarding process and required substantial additional work to maintain and track the return of monitors.

As a receptionist highlighted:

Ongoing monitoring and management

HCAs and nurse staff had key roles in engaging with patients around BP measurement requests and follow-up, with cases requiring clinical attention triaged to clinical leads, and with severe out-of-range cases referred back to the GP or duty doctor (see Table 5). HCAs at North Market Practice HCAs acted more as intermediaries between the patient and the patient’s GPs, managing communications with patients but liaising with GPs for any clinical input or care such as medication changes. Two sites were also able to leverage offsite support teams to deliver TERM BP: North Market Practice had a digital team, including HCAs that were part of the practice, but at a location separate from other practices. PCN staff at the South Coast PCN were located in different offices across the PCN footprint.

In addition to planned workflows and workloads, additional and unplanned work occurred when staff needed to help patients troubleshoot. This related to inaccurate readings due to the use of an incorrect cuff size or an inappropriate measurement technique, follow up with patients not responding to requests for BP measurements, via SMS messages through data platforms, emails, or telephone calls.

A nurse highlighted the workload implications:

Many staff also flagged that paper-based pathways continue to be a route for remote monitoring, especially for those who cannot or do not engage digitally and co-exist with TERM BP. However, the paper-based pathway was associated with a high administrative workload by some staff, a few of whom also raised concerns about potential safety issues if out-of-range readings were not addressed in a timely manner. Given the overall volume of work associated with TERM BP, Mid-Town Practice and North Market Practice worked with community pharmacies to help undertake TERM BP through ambulatory blood pressure monitoring.

How does implementation shape patient uptake and experience, outcomes, and health service impact?

The insights on the implementation of TERM BP across sites, alongside insights interviewees reported about the impacts and influences on implementation (discussed in what follows) suggest that there is no ‘one right way’ for implementation and that tailoring implementation processes to local contexts matters. Similar types of impacts were reported by interviewees at sites implementing varying activities.

Table 4 summarizes key impacts from TERM BP on patients, healthcare staff and services as reported by interviewees.

Impacts on patients

Multiple staff across all sites reported improved clinical outcomes because of TERM BP, primarily improving BP control for patients diagnosed with hypertension, noting improved QOF outcomes. Several staff members, particularly in Green Hills Practice and North Market Practice, attributed improvements to a more accurate measure of BP than one-off clinic readings, reduced risk of human error through automatic averaging, and better ongoing understanding of a patient’s condition through frequent monitoring as needed. Two HCPs in the South Coast PCN also felt that TERM BP helped patients avoid hospitalizations due to the ability to monitor patients more closely on an ongoing basis, although there were no quantitative data to support this perception. A few staff members at Mid-Town Practice and South Coast PCN highlighted improved hypertension case finding, and noted that insights they have from business intelligence tools showed relatively higher proportions of diagnosed patients in practices using TERM BP compared to those in the PCN that did not.

Interviews and workshops with patients pointed to TERM BP helping support a more activated patient population through greater patient awareness and engagement with their health. Staff across sites conveyed that some patients initiated readings on their own, without being prompted by practice.

As one patient flagged:

While there was perceived support for the benefits of BP remote monitoring, some patients also highlighted concerns about technology-enabled pathways excluding those with low digital literacy. We expand this in the section on inequalities.

Impacts on staff and services

Many staff across all sites perceived more efficient working as a result of TERM BP by saving time through decreased in-person appointment time or reduction in appointments altogether (quantitative data to back this perception were not provided). A GP in Green Hills Practice illustrated:

Some clinicians at Mid-Town Practice, Green Hills Practice and North Market Practice also flagged that time savings allowed for better resource allocation, for example more time for patients who need in-person care. As a GP commented:

Even so, and as discussed earlier, many HCAs and nursing staff acknowledged that high administrative workload associated with administering TERM BP in parallel to traditional remote monitoring services.

What influences the implementation and delivery of remote monitoring, and how can challenges be navigated and addressed?

Tables 5 and 6 below provide a summary of key features which supported or hindered implementation across sites participating in the evaluation, respectively. Table 7 draws out key enabling and hindering features related to sustainability, scale and spread of implementation.

1) Ease of technology use for staff

Across sites, many staff members found that the diverse data platforms used to request and receive BP readings were relatively “easy” to use, referring to the intuitiveness of the technology and no need for extensive training. One GP commented:

Prior familiarity with tech platforms also helped in some cases. For example, at North Market Practice, the platform commissioned for TERM BP was already used for other purposes such as appointment booking, so staff were familiar with user interface.

The interoperability between the TERM BP data platform and the GP EHR systems was seen as a key technological functionality essential for adoption at all sites. In general, key interoperability requirements were in place and were seen to support workflow efficiency, for example through the automatic transfer of BP measurements from data platforms to EHR systems. An administrative staff member at the Green Hills Practice explained:

However, some interoperability-related issues were encountered. At Green Hills Practice and Mid-Town Practice, a lack of full interoperability meant that the staff needed to enter some patient information (e.g., medications) manually. At South Coast PCN, staff sometimes needed physically reset connectivity between remote monitoring and EHR systems.

Other functionalities such as batch messaging (of invites or requests for BP measurements) to patients, automatic averaging of BP measurements, and automatic coding using Systematized Nomenclature of Medicine Clinical Terms (SNOMED) for recording clinical patient data were also seen as important for supporting efficient working and save clinical staff time.⁴⁹

2) Supplier willingness and ability to adapt technology offers

Supplier interactions with NHS sites helped enable technological adaptation to support local health system needs.

For example, at North Market Practice, close communications during early stages of implementation helped identify the types of adaptations the site needed and also helped the supplier improve their offer. As illustrated by a staff member:

Support from some suppliers extended beyond initial implementation and ranged from technological design adaptations to staff- and patient-facing software interfaces to virtual or in-person support for staff and patients. For example, at Green Hills Practice, the supplier took on feedback from patients who wanted to be able to add the date and time of their reading, but made this optional so as not to create a barrier for patients who did not need this additional functionality. Some staff at Green Hills Practice, Mid-Town Practice, and South Coast PCN commented on adaptations in areas such as the ability to customize messages to patients, make changes to monitoring duration and frequency, and address connectivity issues between the TERM BP data platform and GP EHR systems to improve staff and patient platform usability. At South Coast PCN, supplier support included a WhatsApp chat, support for patient recruitment via in-person events, and regular software updates to respond to patient feedback. However, despite many staff conveying positive experiences with respect to supplier engagement, at one site a staff member flagged that the levels of support and relationship with their supplier had waned over time.

Supplier ability to adapt technology offers in some ways, for example to offer clinical decision support, was in part also hindered by medical device regulatory constraints, and in particular perceptions of cumbersome and bureaucratic regulatory processes. As one supplier commented:

3) Relationships between regional health systems, local practices, and local health organizations to support TERM BP implementation

The regional health system support for the implementation of TERM BP varied widely. More common types of support for primary care practices or PCNs from ICBs/ICSs (or through HSCPs in Scotland) centred around technology provision through commissioning the data platforms used for TERM BP or for patient identification and population health analytics tools.

Additional types of support were less common. At South Coast PCN, ICB support also included financial incentives for PCNs to meet specific targets for hypertension control, funding new PCN roles such as the digital care coordinator, covering time for one-on-one peer support (by a PCN with established TERM BP implementation to PCNs newly undergoing implementation), as well as facilitating peer networking and knowledge sharing through formal structures such as routine meetings or group chats.

Despite strong support from the ICB at the South Coast PCN, ICB staff commented that initial reluctance from GP leadership in some practices was a barrier to TERM BP implementation and required substantial ICB effort to allay GPs’ unease about patients being managed by PCN staff. Sustained funding has helped increase engagement and reassure GPs that activities contingent on funding of new technology would not be a wasted effort. The digital care coordinator also helped bridge and broker connections between the ICB, PCNs, and general practices. An ICB staff member explained:

Alongside material support, relationships between regional (i.e., ICB, HSCP) and local (i.e., PCNs, general practices) organizations also influenced implementation and varied across settings. At the South Coast PCN, close working between the ICB and individual PCNs and between PCNs enabled overall productive relationships and clear and jointly discussed implementation processes. An ICB staff member illustrated:

Other sites pursuing practice-led models had mixed views of the role of PCNs in enabling or inhibiting TERM BP implementation, with some staff members identifying the need for leadership and cultural alignment across PCN practices for such models to work.

Locally, Mid-Town and North Market practices strengthened their relationships with other local health organizations, such as community pharmacies, to carry out ambulatory BP remote monitoring to manage demand and enable patient access. Staff at North Market Practice also coordinated with gyms through the local council to conduct BP checks.

4) Leadership and organisation of work

Committed and enthusiastic leadership was seen as key for promoting staff buy-in and sustaining delivery across sites. Leadership commitment was often embodied in concrete actions such as establishing delivery programmes for TERM BP services, clinical leadership roles to champion implementation, and multiprofessional teams with clear job roles, workflows and frequent communications.

At the South Coast PCN, a few HCPs emphasized the key role played by the PCN clinical lead in raising awareness about the service across PCNs and practices, and as a focal point for timely support. Across most sites, clarity in roles and responsibilities for different types of staff in TERM BP service delivery was complemented with efforts to ensure effective and frequent communication. A non-clinical staff member from the Mid-Town Practice highlighted:

Team responsibilities, though outlined from the initial planning stages (via flowcharts/protocols) at all sites, evolved and adapted to address issues that had come up, mostly around managing workload. For certain tasks like reading and triaging BP readings, all sites utilized a ‘pooled’ approach which allowed staff with the same roles (e.g. multiple HCAs) to address a common inbox, promoting collaboration and capacity management.

Dedicated time for delivering the TERM BP service helped ensure that tasks associated with TERM BP did not negatively impact other staff responsibilities, although capacity remains a challenge across sites.

As one nurse commented:

5) Willingness and ability to adapt TERM BP service

All sites were committed to a culture of continuous learning and adaptation alongside their initial plans for implementation and a willingness to improve through trial and error. At Green Hills Practice and North Market Practice, this culture was said to have strong foundations in formal quality improvement. Aa GP in Green Hills Practice commented on the openness to try improve by trying new ways of doing things:

Upskilling efforts at all sites (e.g., for nurse associates and HCAs) supported adaptation of the BP service over time. Training – including ‘on the job’ learning- supported staff to understand how to handle/triage incoming BP measurements and gave them the knowledge/confidence to adapt and work flexibly with BP measurement data (including how to manage missing data, i.e. whether a partially completed series of BP readings is sufficient in particular circumstances).

However, many of the new activities delivered by staff in TERM BP pathways occur with limited regulation of novel roles and functions, which some clinicians identified as a barrier to fully utilizing HCAs or other non-GP clinical staff in the TERM BP pathway. For example, although HCAs at North Market Practice liaise between patients and their GPs, their expanded scope in carrying out follow-ups related to TERM BP is seen as a potential risk in the absence of clarification from regulators on expanded roles and the ability or desire for GP partners to take on such risk. As one clinician acknowledged:

6) Patient acceptability of TERM BP

Most patients that we spoke to expressed positive views related to the acceptability of TERM BP services, a sentiment also echoed by staff. Patients we spoke to seemed to find receiving digital care and care from non-GP staff acceptable.

Patients we interviewed and spoke to during a workshop saw particular value in TERM BP providing reassurance, improving understanding and reducing anxiety related to their health condition, but views about the convenience of TERM BP pathways were mixed.

Many patients noted convenience as a key motivator for engagement. To illustrate:

However, some also found it to be inconvenient. As a patient who was a shift worker highlighted:

Two healthcare staff at South Coast PCN and Green Hills Practice also flagged that TERM BP may not be as convenient for patients who have to go to the practice anyway, specifically for hypertension or other reasons.

Most patients also found TERM BP technology interfaces to be user-friendly overall, but some found the limited time windows for submitting readings (quickly expiring links) to be challenging, while others reported difficulties accessing the platform used to upload BP results.

Some patients participating in a workshop said that they lacked confidence in using the technology and raised concerns about whether they were using the devices (e.g. placing monitor cuffs) correctly and about the overall accuracy of their readings. Many expressed a desire for greater reassurance and confirmation that their devices worked correctly. While staff at most sites discussed providing onboarding and training processes for patients, many patients reported receiving minimal guidance from healthcare staff on what monitor to use or how to use monitors and some patients chose to go to the pharmacy to get their BP readings taken “properly” (MTP-2). One participant noted that while she felt confident in taking readings, others may not.

Trust that a healthcare professional was monitoring patient readings and the nature of follow-up communications with healthcare professionals affected patient confidence and trust in engaging with TERM BP, although patients had varying preferences regarding the nature of communication needed. For example, one patient commented that

Another however expressed a desire for verbal follow-up, emphasising that:

A few patients were ‘put off’ by automated text responses. Incidents shared by patients participating in a workshop, where practices lost readings or an HCP questioned the validity of patient submitted readings, also impacted on trust. One patient commented,

The patients we interviewed for this project had all engaged successfully with TERM BP and appeared to have good digital literacy and skills. Many, however, highlighted concerns about others who might not be able to do so, as related to socioeconomic, cognitive, and infrastructure-related determinants of inequalities.

How do considerations of inequalities impact decisions to implement, spread, and scale implementation, and what impact do implementation activities have on efforts to address inequalities?

TERM BP improves access for some patients but is not a solution for all

Use of TERM BP can reduce inequalities in access to care for some patient populations but, for others, it can exacerbate inequalities in the absence of adequate mitigation and management approaches.

For example, a staff member at Green Hills Practice noted that the ability to monitor BP at home helps reduce the need for travel for people living in remote rural areas. Some staff at North Market Practice and Green Hills Practice also flagged that not having to take time off work to go to the surgery helped with patient uptake.

However, staff and patients interviewed across primary care sites generally agreed that the digital requirements of TERM BP increased the risk of excluding individuals without internet access, a suitable device, or digital literacy. Efforts to support digital inclusion across sites involved the provision of devices. Only at South Coast PCN did this also extend to access to the internet and data. Three of the four sites initially loaned out or provided free monitors or discounts for monitor purchase but scaled these offers down due to loss of monitors and lack of supply. Across sites, all of these solutions were limited by waitlists and availability.

Physical and cognitive issues can influence access inequalities. Proactive approaches were taken by some sites to target patients who need additional support. For example, this included staff at North Market Practice visiting house-bound patients and bespoke approaches for patients with learning disabilities or serious mental illnesses at Mid-Town Practice. A few patients participating in a project workshop reported sensory issues causing discomfort with blood pressure cuffs and that visual or physical impairments such as arthritis can also hinder the use of BP monitors. Some patients at North Market Practice used specialized monitors with voice prompts or traffic light systems to overcome these barriers. A GP in Green Hills Practice felt that patients with multiple long-term conditions can find the technology interface repetitive and lengthy to complete.

There are mixed views on the influence of age on patients’ ability to engage. While many staff felt that older adults might face greater challenges with digital literacy and technological engagement, might not have a mobile phone or experience challenges related to frailty, this perspective was not universally shared. A few staff from Green Hills Practice reported that older adults, in their 70s and 80s could engage well, and that engagement among working-age adults between 40–60 was lower.

Maintaining the option for in-person and paper-based monitoring was seen as important to mitigate inequalities in access for patients who could not engage digitally. Most staff viewed these alternative pathways as essential.

Despite the adaptations sites implemented, patients and staff alike felt that more could be done to ensure that TERM BP is more accessible to diverse populations.

What are the key considerations for those looking to scale, spread, and sustain technology-enabled remote monitoring of blood pressure at home?

The insights gained into the origins, implementation, evolution, and adaptation of TERM BP services at primary care sites also shed light on key considerations for local, regional, and national decision makers looking to scale (e.g. reach new patients within the same PCN or same GP practice), spread (implement in new contexts- e.g. spread from one GP practice to another), and sustain technology-enabled remote monitoring of BP at home over time. These insights are based on direct experiences of sustainability and scale at all sites, spread efforts at the South Coast PCN (ICB-governed and PCN-delivered), and staff views about key influences on spread at Mid-Town Practice, Green Hills Practice and North Market Practice based on their general practice-level implementation experiences.

Table 7 below summarises key features impacting on sustainability, spread and scale efforts across the study sites, prior to expanding on key findings in the narrative that follows. Some, but not all of these features mirror those identified as impacting on implementation, but are particularly prominent in the context of spread, scale and/or sustainability.

Funding for sustainability, scale and spread

Efforts to secure long-term funding in resource-constrained health systems have been a key influence on sustainability, spread, and scale. This has been challenging for all sites with many staff flagging that the challenge is accentuated by weak and inconclusive evidence about the impact of TERM BP on service utilization and cost-effectiveness that is needed for a compelling business case for commissioners or for healthcare staff engagement. At South Coast PCN, staff tried to manage the lack of data by referring to local evidence from a neighbouring PCN within the same ICB, indicating reductions in GP consultation time and found this helpful for for persuading GPs across practices to implement TERM BP alongside efforts to secure funding from multiple sources.

Short-term funding approaches in the health system, tied to specific technologies and projects are also a challenge to sustainability, scale and spread, and can, according to staff at South Coast PCN also be a disincentive for sustaining staff motivation and engagement. At some sites (Mid-Town Practice and North Market Practice) staff were resourceful in leveraging technology solutions which they were already using for other purposes (e.g., for appointment booking) and applying them by adapting use cases to TERM BP, minimising the need to continually seek additional funding for technology needed for scaling TERM BP services.

Technology related factors impacting on sustainability, spread and scale

Supplier efforts and abilities to adapt their technology offers had important roles to play in efforts to scale TERM BP services to reach a greater number and diversity of patients. Adaptations included adjustments to patient identification and recruitment based on expansion in eligibility criteria across sites, batching invites to help manage demand and staff workload associated with scaling a service to a greater number of patients, as well as improving interoperability over time across the sites.

Lack of full interoperability (beyond just transferring BP readings, but considering also other relevant patient data like medication use needed to be transferred to EHR) at Green Hills Practice and Mid-Town Practice was seen as a barrier to scale efforts to a greater number of patients, due to capacity challenges this presented when staff needed to manually input data.

Organisational and system’s related influences on sustainability, spread and scale

Committed organizational leadership willing to take on some level of risk – financial, clinical, and regulatory (given limited regulation for new roles staff like HCAs are taking on in delivering TERM BP) has been key to efforts to scale TERM BP services. According to the experiences of staff across all sites, such ‘risk taking’ has been supported through a gradual and staged approach, training and on the job upskilling, alongside clear protocols for escalation of cases needing clinical attention. Drawing on regional support (e.g. through the ICB or HSCP) also helped mitigate practice-level risks. While all sites depended on ICBs/HSCPs for data platform licences, the support for risk management varied from very little else in North Market Practice to funding a new role, providing financial incentives, and creating structures for peer support and knowledge sharing at South Coast PCN.

Common across sites was a gradual approach to implementation and scale that we discussed earlier, were organizational cultures that were open to and embracing of continuous improvement were nurtured. Over time, all sites either recruited new staff to cope with increases in demand or redistributed work amongst existing staff. Sites also adapted TERM BP approaches to manage demand, for example by batching invites to patients and adjusting how referrals to the service were made (Mid-Town Practice, South Coast PCN, North Market Practice).

Similarly, leadership that supported a culture of adaptation and flexibility helped practices develop the resilience needed to sustain and scale TERM BP pathways. All sites started implementing the current version of TERM BP services (in terms of the technology in use) during the years of the COVID-19 pandemic, i.e. around 2020–2021 and three of the four primary care sites had a pre-existing paper-based BP remote monitoring process, two of which had earlier engaged in pilots of TERM BP, which were not continued in their original form but provided meaningful learning that informed the design and operationalization of new TERM BP pathways in terms of staffing (e.g., greater reliance on non-GP staff, pooled working with multiple staff of the same profession type supporting delivery) to support a resilient service. South Coast PCN and North Market Practice also created new structures and roles to enable delivery at scale and to support spread, such as the PCN digital care coordinator role and a back office to centrally handle patient BP data and staff communication tasks by a dedicated digital care team, respectively. Looking ahead, Mid-Town Practice plans to engage more with a local community pharmacy to take readings as a means to reduce the administrative burden on the practice and support long-term resilience and scaling of the service.

Other adaptations that supported spread and scale were tied to financial incentives at South Coast PCN and improved ways of raising patient awareness of the service and of recruiting patients, for example personalizing invite messages and customizing follow up messages across various sites.

Stakeholder collaboration also supported scaling across sites. According to a few staff at South Coast PCN, Green Hills Practice, and Mid-Town Practice, the scaling of TERM BP activities as well as remote monitoring of other conditions has led to an increase in dedicated time needed for existing staff or the hiring of additional staff, and increased the need to collaborate with organisations such as community pharmacy for support with managing demand.

Collaboration between GP practices, the PCN and ICB at South Coast PCN was also seen as important for knowledge exchange and learning to support spread. However, some challenges related to relinquishing control (e.g. from GP practices to PCN) for managing patients were reported as hindering spread at South Coast PCN and staff across sites noted that capacity considerations are a key challenge in spread and scale efforts, especially if there is a lack of resources from local and regional system leads (e.g. ICBs) to support spread and scale.

Enriching the evidence base on implementation, sustainability, spread and scale of TERM BP

This evaluation set out to improve our understanding of the implementation of TERM BP in terms of what works, why, and how, and to draw out learning that can inform the scale, broader spread, and sustainability of TERM BP. This study adds to the currently limited evidence on the nuances of TERM BP implementation.

Diverse implementation contexts were examined, and an overarching structured framework of the TERM BP pathway stages was identified. Within this framework we found both common elements and areas of variation in implementation approaches in terms of how patients are identified, recruited, onboarded, and monitored and managed over time. We did not find evidence of specific technologies and functionalities being more or less useful for different remote monitoring use cases (such as hypertension diagnosis versus hypertension management).

Our evaluation provides practical insight into how different pathway stages are operationalized, which could help decision-makers seek to implement pathways in a new context or to spread and scale them. We surface emergence and the often unplanned or additional work that goes into service delivery (e.g., troubleshooting with patients, finding workarounds for technology issues, managing and maintaining monitors for loans). We explore how various TERM BP governance model options (e.g., practice-level, regional) work in practice. We also shed light on the diverse types of NHS staff who are important for pathway delivery, extending beyond the clinical roles discussed in prior literature, such as GPs, nurses, healthcare assistants and pharmacists,^23,33 to include receptionists and digital care coordinators. Relatedly, we highlight limitations in the current regulation of new service delivery roles and activities, specifically for healthcare assistants. We provide insight into both staff workload distribution and workload in multiprofessional teams to deliver ongoing management and monitoring, as well as parallel paper-based and in person service options coexisting with TERM BP. Such considerations have significant implications for service planning and design, including in relation to required staff capacity, roles, and time, and in workflow planning and risk management.

The insights we gained into the influences on the implementation of TERM BP service pathways contribute to an improved understanding of how and to what extent implementation challenges can be addressed and how TERM BP pathways can gradually evolve and adapt to deliver a feasible service. Many of the influences on TERM BP pathways identified in our evaluation sites are consistent with those identified in the literature, including technological interoperability and integration⁴⁹; ease of use⁵⁰; the importance of clear workforce roles; flexibility in patient recruitment approaches; patient digital literacy^51,52; the nature of information and support for onboarding patients²²; patient and staff relationships and access to funding for the service.⁴⁹ Our evaluation adds by exploring the nuances of how these influences play out. For example, while the literature mainly focuses on the theme of trust in the context of patient trust in technology,⁵¹ our evaluation insights also reveal the importance of staff trusting the accuracy of patient readings in addition to patients’ trust that their data are being monitored. Few studies analyzed in our literature review include detailed information about how patients and healthcare professionals interact around monitoring data^23,33; we explored this and the additional roles healthcare staff take in contacting patients and following up on out-of-range readings.

The evaluation contributes to the scarcity of evidence looking beyond the initial implementation of TERM BP in a single organizational context, to considerations of relevance for sustainability, spread and scale. While many of the influences on implementation in single contexts are similar when considering scale and spread, influences related to longer-term proactive financial and staff capacity planning and resilience, the embedding of skills in teams and systems to avoid single points of failure, staging of volume of activity and adaptation in pathway approaches over time, and consideration of the potentially diverse baselines at which different organizations seek to implement TERM BP services become all the more prominent. We also show how relationships between general practices, PCNs, and ICBs, and the nature and scale of support (financial, coordination, facilitating learning, and exchange) can bolster sustainability, scaling, and spread of service implementation.

Finally, the existing literature examining how the uptake and experience of TERM BP is affected by diverse patient characteristics is highly limited. Some studies do consider approaches to addressing digital exclusion through onboarding processes and guidance.⁵¹ Our evaluation findings point to the importance of running parallel technology and paper-based and face-to-face services to not exacerbate inequalities, and of considering additional outreach for specific patient groups; for example, for patients who cannot engage digitally or cannot easily travel for face-to-face appointments.

Co-evolutionary forces in health and innovation systems underpinning TERM implementation, sustainability, spread, and scale

Our evaluation emphasises that TERM BP pathway implementation is often influenced by interdependent sociotechnical factors, in line with the literature on technology adoption and the NASSS framework.⁵³ As we discussed in the findings, the value proposition for adopter organizations, stakeholders, and the wider system varied, with patient and staff motivations entailing a mix of common and unique factors).

Influencing forces related to the technology and the technology supplier, TERM BP governance and wider health system, workforce, and patient-related influences played out in the gradual routinization of TERM BP services over time, and changes in one aspect (e.g., technology functionalities) influenced changes in others (e.g., ability to deliver a manageable workload and staged service scaling). The confluence of technology enablement and human mediation was integral to TERM pathway delivery. For example, this was evident in patient onboarding (which entailed online resources and direct staff support) and in the dependence of reading accuracy on appropriate human use of technology.

Technological and social influences co-evolved. Wider innovation systems literature^{44,46,54–58} points to an innovating health system as the “process, experience, and result of the interactions between diverse institutions, individuals, organisations, networks, ideas, capabilities, values, and behaviours. These interactions are nested within evolving policy priorities (healthcare policy, innovation policy), changing social, political and economic environments, and dynamic healthcare systems”.⁵⁹ In sociotechnical theory and sociotechnical regimes thinking,^44,45,58 novel sociotechnical regimes (structures that promote stability and persistence) become stabilized by strong alignment between social and technical aspects of a system, and emerge when experimentation gradually transforms incumbent regimes and replaces them.⁴³ This is enabled by shared learning and exchange between experimental niches, policy/political impetus, quality or cost-related benefits, or wider landscape developments that can put pressure on established regimes.⁴⁶

This co-evolutionary dynamic was evident in the implementation of TERM BP pathways, embedding them over time through continual learning and adaptation, and in the perceived determinants of effective scale and spread. For example, adaptability in technology functionalities and the willingness of technology suppliers to work with health system actors – alongside securing funding for TERM BP services, workforce upskilling and reconfiguration, and growing patient acceptance of remote healthcare – enabled sustainable and scalable pathway implementation. Technology functionalities co-evolved with evolving health system needs (e.g. batch messaging and growing demand/patient volumes). Health service practices co-evolved with technology offers to enable embedding and use (e.g.workload reconfiguration and workarounds to deal with technology limitations such as lack of full interoperabilty at some sites). Approaches to risk management (e.g., escalation protocols, cultures of openness to suggesting improvements and seeking support, engaged clinical leadership) co-evolved with the wider technology development and regulatory landscape, helping to address challenges related to a lack of regulation for new roles for functions involved in TERM BP delivery or regulatory barriers to using technological solutions more prominently in clinical decision making.

Co-existing tensions in TERM BP design and implementation

The process of implementation was reflective of the dialectics of organizational and systems change,^40–42 most notably reflected in co-existing tensions between opportunism and active choice. In a broad sense, dialectics refers to aspects of social processes that have to do with contradictions and competing co-existing forces shaping interactions^40,41 emphasizing heterogeneity and a lack of constancy, with destabilizing and competing forces (that are neither inherently good nor bad) as drivers of change in the present order. These forces can challenge the status quo and, in turn, generate adaptation and change.^40,42 Most notably, in relation to TERM BP, these dialectics were reflected in co-existing tensions between demand and capacity, technological possibilities versus regulatory safeguards and constraints, opportunistic versus evidence-driven commissioning, rigidity versus flexibility, planning versus emergence, autonomy versus control, increased versus decreased workload, and patient empowerment versus patient exclusion. Some of these tensions stemmed from features internal to the TERM BP pathway governance and organizational delivery structures and processes, and others from the coexistence of external environmental forces (e.g., financial conditions and the nature of populations serviced by local or regional health services). All tensions were managed through gradual adaptation and evolving social and technical determinants.

To illustrate, in terms of the impetus for TERM BP pathways and their commissioning, tensions between health service demand versus capacity drove a focus on finding innovative ways to deliver needed patient care and manage hypertension as a major public health concern. The interplay of opportunistic versus evidence-based commissioning was also evident and included tensions between managing existing relationships and path dependencies with a degree of criteria-based approaches. This dynamic is exacerbated by the lack of clear national standards and criteria for commissioned services and clear commissioning processes and routes.

In terms of pathway delivery, tensions between technological possibilities versus regulatory safeguards and constraints have impacted the nature of technology applications in patient monitoring and management and on the design of associated risk management in TERM BP pathways. Related to this, coexisting tensions of rigidity versus flexibility also played out in pathway implementation, for example, in determining the extent to which technological functionalities could or could not be adapted to deliver specific functions, such as more advanced medical device functions, in light of regulatory bureaucracy.

Coexisting tensions of planning versus emergence were evident in the diverse areas of adaptation in pathway delivery over time that we have discussed earlier in this paper. Forces of autonomy and control also coexisted in TERM BP pathways with general practices’ views on the needed levels of autonomy, presenting a potential challenge to moving to more ICB-governed models in a spread agenda, depending on funding, cultural alignment, and leadership relations in the system.

Dialectical tensions may also be at play in the pursuit of efficiency in healthcare delivery through TERM BP services, with workload redistribution increasing workload for some staff and decreasing or changing the nature of workload for others. The shift in monitoring activities from GPs to other roles potentially led to overall service efficiencies, but not without coexisting tensions of adding to the workload of some other types of staff (e.g., receptionists, HCAs).

Finally, coexisting tensions between patient empowerment versus patient exclusion played a role in how services sought to manage and mitigate inequalities in access. TERM BP services were seen by staff and some patients to provide value in educating patients about high blood pressure and empowering them towards greater self-management of their long-term conditions. On the other hand, there were concerns that digital approaches would inevitably mean that some patients would not or could not take part, for example, due to digital exclusion or specific conditions that made taking in-home measurements difficult.

Limitations

This study has several limitations. First, the rapid evaluation focused on four sites, centered primarily at the general practice level. Given that we were interested in the experiences of practices with relatively mature implementations of TERM BP, our selection of sites may have introduced bias towards practices that are more advanced and potentially resourced, financially stable, or operationally effective, more generally. In our site recruitment, we aimed to select sites that varied across a number of practice characteristics; however, the primary care sites may not be representative of the experiences and perspectives of all general practices across the UK. That said, we are reassured by the data they share in relation to diverse experiences and the spread of practices across different geographies. Second, the interviews with the staff provided insight into some, but not all, experiences within the practices. Due to resource and time constraints associated with rapid evaluation, each primary care site included perspectives from a limited number of patients; these were recruited through the practices themselves. While the evaluation team engaged with practices to convey the importance of diverse patient views, convenience sampling was part of this process, with a focus on patients approached by general practices who agreed to be contacted by the research team and who agreed to participate in the interview. We attempted but were not able to recruit any carer participants, although a member of the PPIE advisory group was also a carer and brought that perspective. We did not gather data from people who did not participate in TERM BP. Through our patient workshop, we gathered additional perspectives from patients with diverse backgrounds and experiences, to mitigate the limited number of patient interviews.