Project Name: Mid Ulster Primary Care Heart Failure (HF) General Practice (GP) Collaborative Working Project (CWP)

Organisation(s): FEDERATION OF FAMILY PRACTICES OF MID ULSTER Community Interest Company (C.I.C)., Company number NI639091, of Unit 129 The Courtyard Galgorm Ca, Galgorm Road, Ballymena Antrim BT42 1HL

Project Summary:
Novartis and the CW Partners propose this CWP to carry out a review of the participating GP databases in the Mid Ulster Federation. Please see the Appendix 1 of this PID for the full list of surgeries that are in scope for this CWP. 

Novartis will contract with the Federation of Family Practices Mid Ulster C.I.C. on behalf of the Mid Ulster GP Federation, as the legal entity.

Novartis will fund 2 x 0.2 Full Time Equivalent (FTE) Band 8a GP Pharmacists (the “CWP GPP”) to carry out the review of the databases with the participating GP surgeries, and to carry out a medicines optimisation review in line with European Society of Cardiology (ESC) guidelines for all identified patients with heart failure with reduced ejection fraction (HFrEF) . 

The CW Partner GPP will help the GP surgeries with the search criteria to review their patient database(s) in accordance with ESC Guidelines as selected by the GP Practices within scope of this project. The GPP will instruct the GP surgery’ Clinical Pharmacist how to conduct the audit of their patient notes using the search criteria The key priorities and aims for service development are:

  • To raise awareness and education in primary care which in turn will improve management of patients with heart failure (HF) by promoting active case finding, optimising medications and identification of those in need of advanced medicines optimisation/specialist input. In addition to aim to find those patients with a missing diagnosis through reviewing patients who have HF associated risk factors. 
  • To improve adherence to European Society of Cardiology (ESC) guidelines for HF patients to undergo regular reviews in primary care. 
  • Empower primary care general practices to optimise and manage Heart Failure patients in collaboration with Secondary Care Specialist Teams.
  • Percentage increase in patients on the HF register. 
  • Increase number of patients receiving NICE recommended therapies
  • Reduce number of patients referred into secondary care service.

Planned Milestones:

 Milestone Description
1CWP kick-off meeting detailing the project plan. 
activity, roles and responsibilities, and next steps.
Baseline Data  
2Recruitment of new role, training and ready to start.
Identification and audit of GP practices that would like to take part in the CWP.
33 Months data
46 Months data 
59 Months data
6Write up of the CWP.
Write up of the Outcomes Summary.

Expected Benefits:

Anticipated benefits for patients:

  • Proactive assessment and earlier detection of Heart Failure. 
  • Greater opportunity for initiation and optimisation of evidence-based HF therapies. 
  • Reduction in non-elective admissions and readmissions through early treatment optimisation. 
  • Improvement in quality of care. Improved experience of the HF service.

Anticipated benefits for the CW partner:

  • Increase in the overall quality of care for patients with HF. 
  • Improved QoF outcome generated. 
  • Improved recording of HF prevalence rates, enabling comparison with national averages. 
  • Reduction of the inequality gap. 
  • Embedding of the HF pathway within GP practice systems to facilitate sustainability of high-quality care. 
  • Potential wider benefits: if successful, this model of care could be transferred to other areas of chronic disease management, rolling the project out to other federations. 
  • Upskilling Primary Care - improved confidence and competence in delivering optimal evidence-based HF care. 
  • Fostering collaboration between PC and SC, improved communication, and reduction in waiting lists, freeing up clinical space within SC to see more unstable / critical HF patients.

Anticipated benefits for Novartis:

  • Creation of more opportunities for the appropriate use of cardiology licensed medicines in line with NICE and clinical guidelines, potentially including Novartis’ medicine. 
  • Seen as a valued partner in HF across NI – especially with NI Cardiac Network and NI HF Forum. 
  • Better understanding of customer's and patients’ needs specific to the management of HF and potentially more widely.
  • Greater insight into the practical challenges and working of delivering a high quality and sustainable Heart Failure Service.
  • Improved reputation.

Start Date & Duration: The CWP total duration is 14 months, from circa June 24 to July 2025, with 9 months of clinical activity