Using tech to monitor your health at home - what can the NHS learn?

About

One in four people have high blood pressure in the UK - even more in deprived areas. It can lead to heart attacks, strokes, and disability and indicate many other health conditions. Early detection and management of high blood pressure could potentially deliver better patient outcomes and reduce the pressure on NHS services. This is already a long-term target for the NHS.

To help support people, the NHS programme ‘Blood Pressure @Home’ (BP@Home) enables people with high blood pressure to measure and share their blood pressure readings with their GP from home.

In 2021, NHS asked us to help evaluate the programme to see how it is working for patients and how GPs use their readings.

The research focussed on five local Healthwatch areas (Hampshire, Oxfordshire & Bucks, Gloucestershire, Darlington and Hammersmith and Fulham) selected by the NHS. Because we only had limited access to patients on the BP@Home pilot, we encouraged anyone monitoring their blood pressure remotely to take part. Over 480 people responded to our survey, and we also carried out 26 in-depth interviews.

Nine things patients told us

1. People use blood pressure monitors at home for many reasons – not all driven by medical professionals

Only 30% said they were prompted to monitor their blood pressure at home by their GP – with 27% having been advised to buy one and 3% being given or lent one by the GP. More than half bought themselves a monitor unprompted (54%). 

The main reasons for home monitoring include:

• Being at higher-risk, due to factors like age, ethnic minority or pregnancy;
• Wellbeing monitoring;
• For specific health conditions, such as cardiovascular or kidney disease, and;
• Helping with diagnosis.

Other reasons mentioned include medication (e.g. birth control, HRT), family history, family member illness, or their work requires it. A few people said they wanted to avoid ‘white coat syndrome’, which can happen when someone gives an abnormally high reading because of the stress of being in a medical setting.

Getting a blood pressure monitor can trigger a range of emotions, most of them positive (69%). Where there are gaps in information, guidance or communication from GPs, negative emotions arise. The NHS could largely address these by improving GPs’ role in the process. 

At no time did anyone ever explain the reasons for me having the monitor, so I do feel a little frustrated about this. In addition, no one has ever told me I should be submitting the readings, and nor have they rung me to ask me to do so. On occasions, this has made me wonder what the point is in continuing with this.

— Case Study

2. The experiences of those prompted by their GP to use a monitor at home fall short in many ways 

Blood pressure monitors can provide an opportunity to monitor and manage wellbeing or a health condition. They can also prevent far more severe conditions from developing with treatment or lifestyle changes. But the equipment is only one part of the equation. 

For remote monitoring to be effective, both the medical practitioner and the patient must contribute to the process. For people to want to be part of that process, they need to understand what it’s all about, why it’s important for them and what they should do. For many, however, these crucial elements are missing.

3. People were not given enough information about how to use their monitors

It was not clearly explained to 33% of participants  why they should monitor their blood pressure, nor was it clearly explained to 61% of them what happens to those readings when submitted.

When it comes to other information, only:

• 58% were given information on the risks associated with high or low blood pressure.
• 56% were given information on what “normal” blood pressure is for them.
• 49% were given information on the benefits of blood pressure monitoring at home.
• 49% were given advice on changes to lifestyle (e.g., exercise or diet).
• 41% were given information on what blood pressure is.

Most seriously, only 39% of participants were advised what to do if a blood pressure reading is too high or too low for them. 

If my doctor could provide me with some info that explains the readings, so I don't panic and Google stuff.

— Case Study

4. Most find monitors easy to use, but many are not submitting readings regularly

The good news is that 89% of participants agree to some extent that they find it easy to take blood pressure readings with their monitor. Fortunately, blood pressure monitors are generally user-friendly, as:

• 53% had only written instructions to rely on,
• 27% had no instructions at all, and,
• Only a few were shown how to use monitors by health services (16% shown in surgery, 3% given guidance over the phone and 1% shown online via zoom or similar).

Whilst the vast majority find it easy to use the monitor, only 60% agree to some extent that they find it easy to submit readings to their GP practice. This isn’t unsurprising, considering that only 52% found the instructions on submitting readings to the GP practice to be clear.

Services did not ask one in four people (24%) to submit readings at all. This is a missed opportunity for the NHS to identify and treat blood pressure-related conditions. It’s clear that some do take blood pressure readings themselves without prompting from their GP, but others find the perceived lack of interest from their GP demotivating.

I made an appointment because my blood pressure levels had increased… the nurse couldn't have been less interested…. I have a family history of heart disease.

— Case Study

Worryingly 15% of participants who were prompted to use a remote blood pressure monitor by their GP were neither asked to submit readings to their GP nor told what to do if they had a high or low reading – leaving them vulnerable.

5. The NHS is not getting the most out of remote monitoring technologies

Many participants were asked to monitor their blood pressure for just a short time (a week, a month or until their blood pressure stabilises). Services asked only 24% of people to monitor their blood pressure on an ongoing basis – pointing to further missed opportunities.

One of the major frustrations for participants was that there was no way to submit their blood pressure readings to their GP electronically.  Nearly half of the participants still had to use a paper-based system. When asked how the NHS could improve the process, many expressed, unprompted, that they would like to be able to submit readings electronically via an app, email, website or SMS.

Being able to email the results to my GP practice instead of dropping in a handwritten note or waiting forever for someone to answer the phone at reception!

— Case Study

6. There are positive signs that GPs are contacting people about their blood pressure

Over two thirds (68%)  had been contacted by their GP for something related to blood pressure monitoring, for things like prescribing medication or for diagnosis, which is encouraging.

Just over half had contacted their GP themselves about their blood pressure, and for a third, it was due to concerns about a blood pressure reading.

Increased use of blood pressure monitoring at home could increase demands on GPs. However, developing a digital system for collecting, assessing blood pressure readings, and delivering automatic feedback, could potentially reduce some of the phone and face-to-face contact and the manual checking of readings by NHS staff.

For participants not prompted to monitor their blood pressure by their GP, 60% contacted their GP about their blood pressure, which increases demands on GP time, but hopefully reduces the incidence of much more severe conditions and better outcomes for those people. There is an appetite for using an app or website to record and submit blood pressure readings.

Only 7% of all participants already use an app or website to submit readings to their GP. Of the remaining participants, 72% would “definitely” or “probably” consider using an app or website, which is promising for a future move to more digitalised data systems and processes in the NHS. However, it’s essential to remember that age and 
digital confidence could be a barrier, and these disparities need to be considered in any move to digital systems.

I rely on my son to help me as I am not good with technology.

— Case Study

There is a range of reasons why participants would not choose to use an app or website to submit readings. The NHS should carefully consider these in the rollout of such a development, particularly around the messaging used to promote it.

The top reason people gave for potentially not submitting a digital reading  was that it was “too much hassle”. Given this, an app or website must be as simple and accessible as possible.

I have found most NHS apps/websites confusing, do not function at all well.

— Case Study

7. People are willing to continue monitoring blood pressure remotely

Most participants will continue to occasionally or regularly take their blood pressure (88%). A few have stopped or will stop because their blood pressure is under control or their GP only asked for readings for a limited period. However, it might be an idea to encourage people still to carry out occasional checks of their blood pressure from home. This action could be prompted by either their GP or an app. 

I was asked to submit one week's readings (am and pm), as a one-off.

— Case Study

8. 63% preferred monitoring their blood pressure at home, but some still want the reassurance of being checked by their GP

Although most people prefer monitoring from home, some said they would like the reassurance of their blood pressure being periodically checked by a medical professional. This would help overcome fears that their monitor is not working or that they are not taking the readings correctly.

The collection of and response to blood pressure readings by GPs could provide the much-needed reassurance and the motivation needed for these participants to continue monitoring and protecting their health.

9. Patients identified several ways to improve their experiences with remote blood monitoring

Being able to submit readings digitally via an app or website (and make it easier in general) is key to improving the remote blood pressure monitoring experience. 
Getting results checked by a GP and receiving feedback based on those results are also important factors. If patients feel that they are dropping readings into a “black hole”, they are left worrying about the results and are demotivated to continue monitoring.

Blood pressure monitoring at home has the potential to deliver positive outcomes for patients, but these aren’t being fully realised.

Over 70% of participants agree to some extent that:

• Getting a blood pressure monitor helped them understand their blood pressure and what it means for their health (75% agreed).
• Monitoring their blood pressure gives them peace of mind (73% agreed).
• It saves them a lot of time and effort going to their GP practice  (71% agreed).
• It has made them more motivated to keep their blood pressure in check (71% agreed).

Only 55% agreed that getting a blood pressure monitor led them to take steps toward a healthier lifestyle. Even more concerning, only 33% agreed that their blood pressure has stabilised or improved since they started monitoring their blood pressure.

Due to a lack of information and guidance, the NHS may not equip some patients to make the changes required to reap the benefits of remote monitoring. Simply using a monitor at home is not enough - there needs to be a supporting process around it.

If I had the equipment and appropriate knowledge to monitor anything about my health, I would do it. I believe we have to turn away from picking the phone up and ringing the GP and we need to take responsibility for ourselves through changing our lifestyles and doing some exercise.

— Case Study