Helping with workload?

Primary care interviewees framed the BP self-screening equipment as assisting with the workload of checking BP—particularly those checks triggered by administrative reminders—rather than as a tool to reduce undetected hypertension: “You know about QOF pop-ups and things? …‘This person hasn't had their blood pressure checked for 5 years’ and they're somebody that never comes to the practice and you really want to catch them and do it then, but you're already running half an hour late…” (GP, Practice E with BP self-screening, (BPSS)). While it was acknowledged that checking BP was good practice, it contributed to the workload of already busy surgeries: “QOF want BP measurements for pretty much everybody … it adds, you know, another few minutes to every single patient … clinician time is always at a premium” (Practice Manager (PM), Practice Bl, BPSS in set-up). BP self-screening was felt to help free up time in consultations and the number of patients requiring appointments specifically to get their BP checked: “They [the GPs] are happy because, like I said, they can send the patient straight out and say, ‘Go check your blood pressure’ rather than trying to find an appointment with a nurse or a health care assistant” (PM, Practice W with BPSS).

The perceived benefits on clinician workload and also its ability to detect undiagnosed hypertension were largely unaudited: “I don't have any ideas about screening… it's just anecdotal, I don't know” (GP, Practice S with BPSS). For some, there had been concerns prior to operationalisation that self-screening could actually increase the number of measurements taken in consultations: “We thought…we're going to get inundated with slightly iffy results and we're going to end up checking it more but that's not been the reality” (GP, Practice Wg, with BPSS). One GP, whose practice had decided against getting the equipment, was concerned that the stress of publically measuring BP in the waiting room would cause inaccurate readings. This, in turn, could cause unnecessary patient anxiety: “It had the potential to kind of sabotage reasons that people might be coming to their GP, if their primary concern had been something else but they came and then had a high blood pressure reading, for all sorts of silly reasons” (GP, Practice C, without BPSS).

Useful information?

Within our sample, there was variation in what the GPs were willing to use the self-screened results for. For screening purposes, all used it as a ‘rule-out device’ but would repeat elevated self-screened results themselves: “If they've then got a low result I'll be happy to accept that and put it into the computer… whereas if it's high I would always check it myself again before making any treatment decisions on the basis of that result” (GP, Practice E with BPSS).

Some surgeries used the waiting room monitors largely for the management of patients with hypertension. These readings were nested among office measurements—on the basis of which treatment was initiated—and, for some patients, alongside home monitoring. There was uncertainty regarding the comparative accuracy of self-screened BP measurements: “My perception… is that the results are usually lower when they do them in the waiting room and probably more accurate, so more closely tied to home readings” (GP, Practice E with BPSS); “I would put, put it closer to an office reading…. you're in in a medical environment” (GP, Practice C without BPSS). Owing to uncertainty about the accuracy of self-screened results, including patient adherence to the measurement protocols, one GP preferred to repeat all measurements taken in the waiting room when monitoring patients with hypertension thus negating any potential timesaving benefits: “It takes a minute to check someone's blood pressure. So, I mean, I'll be checking it anyway whatever that [the waiting room monitor] says” (GP, Practice Wg with BPSS).

There was also doubt about how many repeat measurements should be taken: “Some patients just have a single one and some patients do it three times and then you end up with three little slips of paper. And there aren't instructions for that….it's a bit kind of random” (GP, Practice S with BPSS). Some practices requested three readings while others used a single measurement: “One of the other practices … had a big list by the side of it that said, ‘If your blood pressure is at this point wait fifteen minutes and take another reading. If your blood pressure is at this point do nothing, come back again in a week's time and try again’ and all these things and we thought the more complicated you make it…, the more problems you get …So we looked at it very simple, take one” (PM, Practice K with BPSS). Practices had reached different conclusions regarding the trade-off between minimising measurement burden and maximising the accuracy of readings.

Empowering patients—an opportunity missed?

Providing facilities for patients to check their own BP was recognised as an opportunity for health promotion and patient education: “Obviously people should ideally know their numbers and by that I mean be informed about what's normal” (GP, Practice S with BPSS). However, this was a secondary benefit when compared with reducing workload. In spite of the opportunity to improve patient knowledge, there was limited provision of information alongside the monitor: “We haven't thought about doing that I suspect that would come under the heading of a little knowledge is a dangerous thing” (PM, Practice Bl BPSS in set-up). There was very limited offsite promotion meaning that only patients already attending—and engaged with—primary care were aware of the facilities to check their own BP.

Location: privacy versus accessibility

Taking BP measurement outside of its traditional setting of a 1:1, private healthcare consultation triggered reflection of where best to place the BPSS equipment: “… a personal service going on in a public waiting room… we just felt slightly uneasy with that” (GP, Practice C without BPSS.). There was no one ideal location within the conventional spaces of a GP surgery: “We really just put them where we could find space that's a bit private. So we've got one with a seat at the bottom of the stairs…a kind of a cubby hole” (GP, Practice S with BPSS). There were mixed views about the use of partitions to screen service users: “We're going to buy a screen cos currently it's just open in the waiting room so anyone can see you sitting there sticking your arm in the machine and we've listened to, sort of, patient suggestions” (PM, Practice W with BPSS); “When it was behind a screen … it was almost more off putting to go in” (GP, Practice Wg with BPSS).

Pharmacy checks—part of the job

Five interviewees represented four pharmacies, three of which offered professional-led BP checks. For pharmacies, provision of BP checks was linked to their dual identity as a place of healthcare and as a retail space; although a commercial enterprise, it is one with a social conscience: “You do it [BP check] as a kind of service to the community that pharmacies offer. But, just like we give free advice all the time and stuff like that, it's part of the job” (pharmacist Bb with BP checks). BP checks were felt to be exempt from the business model as they were of public health value. Although pharmacists liked providing the service—“I think it's actually quite a nice thing for the pharmacist to do. Breaks up the routine of the day, doesn't it a bit?” (pharmacist Bc with BP checks)—its promotion was limited due to lack of direct commercial benefits.

Pharmacy BP checks were triggered by physical symptoms or conducted as part of medication review appointments: “I tend not to push it on them. Most people come to me and say, ‘I'm not well and I think my blood pressure’ or whatever then I would do it” (independent pharmacist O with BP checks); “I'll tie them in with MURs [medicine usage reviews] …‘How often do you have your blood pressure checked?’ … Would you like to me check it now?’”(pharmacist Bc with BP checks). There was little evidence of asymptomatic members of the public requesting to have their BP measured, that is, for screening purposes.

Different service models were used—some pharmacists conducted the whole process: “If I let anyone else do it, I then can't see the patient and find out a bit more. I would have to waste time by asking someone to tell me what was said” (independent pharmacist O with BP checks). In others, the measurement was conducted by an assistant following a protocol: “If it's a really high one, I tend to get [the pharmacist] to do the advice which is his job rather than mine” (pharmacy assistant Bb with BP checks). Interpreting the reading was recognised as requiring skill: “Any idiot can do blood pressure readings, it's understanding what it is like” (pharmacist O with BP checks).

For one smaller pharmacy, a lack of staff, training and suitable space were barriers to providing a BP screening service: “I'm the only pharmacist here. I just have two members of staff who are trained to work in the medicines counter but nothing else” (pharmacist Bf without BP checks). The pharmacist also acknowledged the local general practice's library of home and ambulatory BP monitors available for patient use: “that's certainly way beyond anything I can offer” (independent pharmacist Bf, without BP checks). It was felt starting a pharmacy-based service may cause duplication of effort and the potential to upset the local practice: “Until they [the clinical commissioning group] express a definite desire for this to happen then I'm steering out of it.” (pharmacist Bf, without BP checks).

BP self-screening in community locations—an odd thing to see?

Apart from some pharmacies and the health bus, no other community sites offered BP checks. Interviews revealed that several were involved in other health-related activities, for example, a mental well-being self-help reading list at the library and healthy eating events at the supermarket. These, however, had a tangible link to the site's raison d'etre, something that was harder to demonstrate with BP screening: “It would be an odd thing to see a blood pressure machine apropos of nothing, you know, without some sort of context to it” (community centre manager without BP checks); “We're very limited for space. Space is for selling which is ultimately the main thing, reason, we're here” (supermarket representative without BP checks).

While community interviewees expressed an interest in promoting well-being and neighbourhood involvement, it was unclear what benefits hosting BP screening would provide them: “It might bring more people [in] but I'm sceptical about that” (advice centre representative without BP checks). The organiser of the health bus—the one community location that did offer BP measurements—described limited public interest and the effort required to drum up service users: “It's hard slog, you know, people don't just come rushing out and say ‘Oh yes, please take my blood pressure!’” (community worker with BP checks).

Interviewees reported minimal health service impetus to set-up BP screening services with no sites having been approached by healthcare commissioners. For sites with no history of providing BP checks, there was no experience or expertise to draw on: “They [service users] would start asking me questions that I wouldn't be confident to answer” (Daycentre worker without BP checks). These concerns were echoed by others: “Would it be an extra responsibility for us? Or would somebody come and service it or look after it… or do we need to train people” (optician without BP checks). There were also concerns that a poor self-screening experience may reflect badly on their organisation.

Table 3 summarises the findings of the studies and areas of uncertainty regarding BP self-screening identified.