Project Name: West of Scotland (Cumbernauld Cluster) - Heart Failure Audit and Medicines Optimisation Collaborative Working

Project Summary:

The Collaborative Working Project (CWP) with seven general medical practice sites (Cumbernauld Cluster Practices) within NHS Lanarkshire has three main aims:

  1. To identify known patients with heart failure with reduced ejection fraction (HFrEF) in each general practice and optimise their current heart failure (HF) medications in line with local HF guidelines within the primary care setting.
  2. To identify suspected, but currently undiagnosed, HF patients and refer such patients via the NHS Lanarkshire Heart Failure Diagnostic Pathway for formal diagnosis of HFrEF via echocardiogram.
  3. To better manage known HFrEF patients within these general practices on an ongoing basis. In addition, it will support with new HF patient identification.

The seven practice sites belonging to the cluster are as follows;

  1. Condorrat Health Centre, 16 Airdrie Rd, Cumbernauld, Glasgow G67 4DN
  2. Caledonian Medical Practice (Formerly Kildrum Health Centre), Afton Rd, Cumbernauld, Glasgow G67 2EU
  3. Caledonian Medical Practice, North Carbrain Rd, Cumbernauld, Glasgow G67 1BJ
  4. Glen Medical practice, 17 Auchinbee Way, Cumbernauld, Glasgow G68 0EZ
  5. Kenilworth Medical Centre, 1 Kenilworth Ct, Cumbernauld, Glasgow G67 1BP
  6. Abronhill Health Centre, 15 Pine Rd, Abronhill, Cumbernauld, Glasgow G67 3BE
  7. Dr D J Clifford Medical Practice, Abronhill Health Centre, 15 Pine Rd, Abronhill, Cumbernauld, Glasgow G67 3BE

Planned Milestones:

1Identification of integrated patient pathway
2Initial Project Set-Up with Third Party Provider, Interface Clinical services (ICS) with whom Novartis have contract in relation to these activities
3Heart Failure (“HF”) Prevalence Improvement Service and Heart Failure: provision of a proactive risk management tool, and GP practice education in its use
4Pharmacist-led HF patients’ notes virtual (or in-person as required) review
5Interface Pharmacist-led patient facing clinics for HF patients
6Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary

Expected Benefits:

Benefits to Patients:

  • Improved access to diagnostics (echocardiography) and optimisation of heart failure medications and treatment
  • More equitable and consistent care and access to care
  • “Care Closer to Home” potential
  • Improve the quality of life of HFrEF patients and decrease the rate of re-hospitalisation or readmission following an acute decompensation of HF. 

Benefits to NHS Organisations

  • General practices can complete data cleansing and confirm the patient is diagnosed with HF via echocardiogram
  • Increase the overall quality of care and improve equity of access to primary and specialist care for patients with HF 
  • Improve knowledge and competence within primary care and increase advocacy and awareness of HFrEF patients and ensure they are managed with an optimal therapeutic regimen.
  • Development of understanding of coding and management of patients which may inform ongoing redesign and workforce planning at a national level through Heart Failure Hub Scotland

Benefits to Novartis

  • Further opportunities for the appropriate use of HF licensed medicines in line with local guidelines, including Novartis’ medicines
  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisations

Start Date & Duration: 

Initiation: September 2023
Duration: 9 Months