Table 8 Barriers to implementation of target behaviours mapped onto NPT mechanisms, and possible solutions mapped onto the Expert Recommendations for Implementing Change taxonomy

Doubts about the thresholds used to escalate medication

Low coherence

Adjusting the mismatch between the legislative targets of 150/90 mmHg (NHS England 2018) and the evidence-based targets of 135/85mmHg.

Involve executive boards

For some practitioners, applying an algorithm to promote clinical decisions creates perceived conflict with delivering patient-centred care and shared-decision making

Low cognitive participation

Using an approved checklist [37] to inform criteria for distinguishing appropriate inaction from clinical inertia, to allow clinicians more flexibility in decision-making, whilst still encouraging medication escalation in cases where clinical inertia can occur.

Where a practitioner decides not to escalate medication, the checklist could prompt them to plan when they will review their decision and any interim actions agreed with the patient, such as lifestyle change.

Promote adaptability

Patients’ blood pressure readings are close to the target

Low coherence

Tailored email prompts with evidence for the benefits and safety of lowering blood pressure below the target.

Tailor strategies

Wanting to wait for more evidence from further home blood pressure readings before making a medication change

Low interactional workability

Improved tracking capacity to allow practitioners to view patients’ readings over time and see cumulative evidence for medication escalation.

Clinical Performance Feedback Intervention Theory describes several mechanisms for optimising the effectiveness of audit and feedback systems, including trends to show patient’s performance over time, and benchmarking to allow comparison with other practitioners [42].

Audit and provide feedback

Concerns about risk of hypotension following a medication change

Low reflexive monitoring

Tracking could reduce perceived risk of escalating medication by enabling practitioners to check patients’ clinical status after an escalation.

Audit and provide feedback

GPs’ concerns about one-way notifications for patients not being received

Low cognitive participation

Some SMS systems already used in Primary Care allow patients to rapidly acknowledge receipt, which could increase feasibility of patient notifications for GPs.

Obtain and use feedback from patients/consumers and family

Some nurses had concerns that one-way notifications conflict with their role of providing tailored patient support

Low coherence

Provide facility to allow nurses to enable two-way communication with patients if they wish to.

Involve patients/consumers and family members