CVD is the biggest cause of preventable early mortality and health inequalities in our communities. The risks from CVD have increased post COVID. Controlling BP is one of the best ways to improve CVD outcomes.

BP@home is a programme to improve BP control in people with hypertension through home monitoring by:-

• identifying who is at greatest risk from their hypertension
• recruiting patients to either buy their own BP monitor, or if unable to, supplying a free BP monitor, and providing resources for guided self-monitoring
• monitoring their average home BP using a structured process.

The flowchart and FAQs are provided to help speed up the implementation of BP@home.

Practices are free to utilise their own methodology to identify who would benefit most, recruit them into the BP@home programme, and manage their BP. However, practices do need to use the correct coding when using BP machines that have been supplied:-

• 413606001 | Average home systolic blood pressure (observable entity)
• 413605002 | Average home diastolic blood pressure (observable entity)
• 1085031000000100 | Home blood pressure monitoring declined (situation)

As a minimum, practices taking part should supply the 'free' BP machines to patients in greatest need but the ambition over the next 12 months is to try and increase the number of people with hypertension who are controlled by around 2,500 patients across NHS North Yorkshire CCG, based on 2019/20 QoF data (equivalent to around an additional five or six patients per 1,000 practice population.

If that is achieved, it is halfway to the ambition that 80 per cent of all patients with known hypertension are controlled.  (see here for more information about where these number have come from).

The use of self and telemonitoring of blood pressure is supported by evidence as it is: cost-effective, saves GP time by shifting care from GPs to other members of the multidisciplinary team, produces a clinically significant reduction in BP compared to usual care, and over five years reduces the incidence of clinical events such as death, heart attack or stroke.