Transformation Directorate

Culture, capability, and co-design – how technology-enabled remote monitoring is helping move the dial towards empowered personal care in Dorset.

Delivered in partnership with AHSN Network.

Hundreds of people in Dorset are being supported to take control of their long-term conditions from the comfort of home thanks to a step-change digital programme expanding across the region. NHS Dorset’s Digital Access to Services at Home (D@SH) programme is shaped by a multidisciplinary team of clinical and non-clinical specialists, thinking differently about how to best care for and empower communities.

The team aims to embed equitable digital access for all through innovations like technology-enabled remote monitoring, without creating additional dependencies on patients, people or those who care for them.

This work is catalysing a behavioural shift among the population, encouraging better self-management of long-term conditions through digital support and tools.


Nearly half of Dorset’s population is aged between 20 and 54 and, in common with other regions, many people have long-term conditions associated with lifestyle choices or getting older, including hypertension, arthritis, diabetes, and COPD.

Insights into Dorset’s population and digital literacy of different groups, such as those with diagnosed or undiagnosed hypertension, is a key element of best supporting people and reducing health inequalities.

This work is also busting myths about the potential use of technology-enabled remote monitoring and other digital services by age, gender, and deprivation. This includes the perception that people living in areas with high levels of deprivation are less likely to access this technology, with a homeless patient already onboarded to the service amid ongoing engagement work with different communities in the region.

A workforce infrastructure including digital champions, data ambassadors, digital health advisors and care coordinators underpins the service’s ongoing progression, with an integral focus on developing digital-clinical leadership and education. Working with development and workforce teams, D@SH has been able to fund local digital fellowships and create both communities of practice and networks for professions including nursing, pharmacy, and allied health.

"We know from surveying more than 44,000 residents that about 33,000 are willing or able to use technology as part of their care. More than quarter of those, for instance, are hypertensive. This means thousands of people could be supported in a different way, such as through remote monitoring. Such insight helps us understand and offer support to those who want to develop their own digital skills, helping us to work in a different way and appropriately release precious capacity in our clinical teams to see those who require face to face services.”

Crystal Dennis, Head of D@SH

“Digital care coordinators are proving to be the absolute key for this project across our primary care networks. They’re there to engage with patients and are a vital interface between the technology and the clinicians.”

Louise Bell, Dorset CCG clinical fellow and Hypertension at Home clinical lead


From risk stratification and population segmentation to assessment of impact, data analysis supports D@SH to enable and scale its remote monitoring services, encouraging a maturing use of the same tools by Dorset’s primary care networks.

With a lens on identifying need and reducing inequality, the team analyse population intelligence information including primary, community, mental health, social care, and acute data hosted by Dorset intelligence and insight Service (DiiS).

In addition to 330 monitors received from NHS England, the team purchased 2,000 blood pressure cuffs, funded by Dorset Local Enterprise Partnership, to distribute to patients and GP practices, helping reduce any health inequalities for people who may not be able to purchase a cuff of their own.

A problem-first, rather than solution-first, approach helps the team identify and then co-design new digitally enabled care pathways involving both clinical teams and patients.

A digital clinical safety assessment for every pathway ensures all potential causes of harm to patients using the technology are transparent with users. Any such cause is mitigated through risk management processes led by digital clinical fellows, supported by both communities of practice and professional networks.

Crystal said:

We consider ethics alongside personalised care. Just because we can do something with technology does not always mean that we should. We work with many stakeholders from patients to enterprise architects, clinical safety officers, information governance leads, shared care records and clinicians to ensure best use of our digital toolkit. Digital disconnect is a real consideration for the team and we have an oversight of all the patient portals in the system linking in with National Digital Channels Board, so that we can be assured our offer will continue to mature and be fit for purpose.


Embedding supportive self-management for patients is key to the team’s activity and is helping drive a behavioural shift among Dorset’s population. This developing culture of empowered self-management is also supported through key partnerships, such as with Livewell Dorset. Together, teams are supporting people to make changes to behaviours including exercise, smoking, food choices and alcohol.

Crystal said:

This project has shown that pharmacists and advanced nurse practitioners as well as non-clinical roles can manage our hypertensive population, escalating to a GP when appropriate.

Louise Bell, Dorset CCG clinical fellow and Hypertension at Home clinical lead said:

The patient is at the centre of all of this. They love the fact they’re beginning to understand conditions like high blood pressure and can take control. The service is helping to improve both their health and lifestyle. It’s important to have clinical leadership and to gain perspective of how things work on the ground, along with buy-in from all levels from managing directors and healthcare assistants, to the nursing team and clinical pharmacists.

Tools and Technology

The BP@Home programme is powered by Omron Hypertension Plus software, purchased by the D@SH team for 38 practices across Dorset.

This includes a patient app that helps track blood pressure readings in line with NICE guidelines and provides educational support to the patient, and a clinicians’ dashboard that enables alert notifications for patients who submit an uncontrolled reading, along with medication titration tracking.

While this dashboard has a separate login, average readings are automatically uploaded weekly and coded to the GP system, SystmOne, and patients have a marker on their record to show they are participating in the BP@home project.

Louise said:

Key ingredients to success include having the right technology and a safe and equitable platform for patients. Patients don’t necessarily need face-to-face appointments. The readings they send come through to our dashboard and we can intervene accordingly. Not only does this save the patient time and is more convenient, but it also saves clinicians’ time and helps reduce the environmental impact of the NHS.

Accompanying digital tools for patients, like vital sign monitoring, education, courses, symptom-tracking, and medication diaries are also catalysing the culture of people getting to know their health conditions and making positive lifestyle changes.

Crystal said:

The technology supports different parts of our workforce, including nonclinical roles like health coaches, care coordinators and health care assistants, to manage demand in a different way, escalate when necessary and tailor care effectively according to need.

Benefits and impact

More than 31,000 blood pressure readings have been recorded by more than450 patients since the project fully launched in March 2022.

Patient testimonials include:

Using the app has encouraged me to make improvements.
It’s good seeing my blood pressure and being able to monitor it and watch the progress.
I’ve used the tips to improve my lifestyle. I’ve reduced red meat and salt.

Early data suggests this work has reduced the number of GP visits and improved management of a patient’s condition through access to diagnostic blood pressure readings.

Crystal said:

One example of BP@Home impact is a patient who submitted five uncontrolled readings over their monitoring week. Previously, each would have required a 15-minute clinical appointment to review and provide an updated medication plan, resulting in a total time of 1hr 15minutes. The new process meant the medication changes happened virtually with only one clinical appointment required.

Since the project launched to July 2022, the programme has also reported:

  • 55% cost saving on patient appointments, by optimising GP and workforce activity and time per patient
  • 45% reduction in hypertension patient appointments
  • A productivity value increase of £181,000

Crystal said:

Due to the way our health system works across organisations there is not always coded data, or the quality of consistent coding of data, to show impact, so it is vital we hear from partners. For instance, one practice case study shows a patient had submitted dangerously high blood pressures that we would refer to as malignant. Had he not submitted those readings and the clinician received the urgent alert via the dashboard he was at incredibly elevated risk for CVA (stroke), but this was prevented with the initiation of antihypertensive therapy by his GP.

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