Project Name: Mid Ulster Primary Care Heart Failure (HF) General Practice (GP) Collaborative Working Project (CWP)
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..
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) (as per the request of the collaborative working partner)
The CWP 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 CWP 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 | |
|---|---|
| 1 | CWP kick-off meeting detailing the project plan. activity, roles and responsibilities, and next steps. Baseline Data |
| 2 | Recruitment of new role, training and ready to start. Identification and audit of GP practices that would like to take part in the CWP. |
| 3 | 3 Months data |
| 4 | 6 Months data |
| 5 | 9 Months data |
| 6 | Write 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
Amendment time extension to Dec 2025
FA-11481811 | July 2025
Project Name: Mid Ulster Primary Care Heart Failure General Practice Collaborative Working Project
Organisation(s): Federation of Family Practices of Mid Ulster
Completion Date: 4th November 2025
Outcome Summary:
Following a comprehensive review of patient databases across 10 GP surgeries, all eligible patients underwent a medicines optimisation assessment. As a result, 370 individuals were provided with a tailored Heart Failure Management Plan and given access to self-care resources, representing an improvement compared to baseline.
Key Project Outcomes Data:
The General Practice Pharmacists (GPP) conducted a database review across all 10 participating General Practices. There were 421 patients at baseline on the HF register. This increased to 526 after completion at 9 months. During this period, 80 additional patients were optimised in line with the ESC Guideline recommended 4 Pillars of Care1.
Outcomes:
2 General Practice Pharmacists conducted database audits at the GP practice level across ten surgeries, using search criteria provided by the CW Partners. This process revealed variations in prescribing patterns and prompted a medicines optimisation review for all eligible patients. Each practice hosted review clinics, and multidisciplinary team (MDT) consultations were held—11 virtually and 2 in person—with the Lead Consultant Cardiologist at NHSCT. A total of 370 patients received individualised Heart Failure Management Plans and access to self-care resources, marking an improvement from baseline.
During a nine-month period, 80 additional patients were optimised according to the ESC Guideline’s recommended four pillars of care1, 68 patients were optimised to three pillars, 25 to two pillars, and 7 to one pillar of care.
Across the 10 General Practice Surgeries, patients experienced earlier identification and proactive assessment of Heart Failure, resulting in increased opportunities for initiating and optimising evidence-based therapies. These improvements are expected to lead to fewer non-elective admissions and readmissions, enhanced quality of care, and a better overall experience with the Heart Failure service
Benefits for the CW Partner included an increase in the overall quality of care for patients with Heart Failure with improved QoF outcome generated. The database audits improved the recording of HF prevalence rates, enabling comparison with national averages, and reduction of the inequality gap.
A further benefit in improving confidence and competence in delivering optimal evidence-based Heart Failure care within a primary care setting, resulting in upskilling and HF service improvement, and empowering primary care general practices to optimise and manage Heart Failure patients in collaboration with Secondary Care Specialist Teams, improved communication, and reduction in waiting lists, freeing up clinical space within secondary care to see more unstable / critical HF patients.
Quote from Partner:
Loraine McHugh
“This project has had such a significant impact on the quality of care given to HF patients within the federation, with many patients being moved up to 3 or 4 pillars of care1. Multiple patients reported an improvement in their symptoms, quality of life and exercise tolerance as a result of medicines optimisation.
In one notable case, a 79 year old gentleman, NYHA Class II, reported only tiredness as his main symptom. During the face-to-face consultation, I assessed pulse and found him to be significantly bradycardic at 34bpm. I arranged for an urgent ECG to be performed that day and it showed high grade AV block. After consulting with the GP, I contacted cardiology and they arranged for an immediate ambulance as he was at high risk of asystole. A pacemaker was fitted the following day. Afterwards, the patient contacted me to express his extreme appreciation for the review and my timely actions as the cardiologist advised him that it potentially saved his life.“ Loraine McHugh, General Practice Pharmacist.
Niall O’Kane
“A further positive impact has been the training and upskilling of other General Practice Pharmacist (GPP) colleagues. Most patients have to wait several months to see a HF nurse specialist following an ECHO or discharge from hospital. This project and subsequent training has encouraged my fellow GPPs to take a more proactive approach in the optimisation of medications in line with HFrEF ESC guidance. It has given them the support and confidence to action these medication changes, knowing that there are specialist HF pharmacists within the team to guide any decision making. To date, two colleagues in different Federations, who have seen the impact made in the Mid-Ulster federation, have reached out for guidance on conducting their own searches as part of quality improvement project. It has also helped GPs to proactively manage LVSD as opposed to symptomatic control.
On a personal level, this project has been extremely rewarding. Optimisation of medications provided short term symptomatic improvements along with longer term benefits. They were grateful to be called for review as many had been previously discharged from secondary care. Appointment invitation and attendance rates were high with patients appreciating any help that may improve their life expectancy, quality of life and reduce potential future hospitalisations. Many patients were appreciative for the reinforcement of education, discussion around their condition, the ability to raise any concerns, safety netting and reassurance on the management of their condition.“ Niall O’Kane, Lead General Practice Pharmacist.
Conclusion:
Across the 10 General Practice Surgeries, patients experienced earlier identification and proactive assessment of LVSD, resulting in increased opportunities for initiating and optimising evidence-based therapies.
These improvements are expected to lead to fewer non-elective admissions and readmissions, enhanced quality of care, and a better overall experience with the Heart Failure service.
The two GPPs were able to upskill themselves, increase communication with secondary care colleagues and help to develop other GPPs and GPs in primary care to effectively improve the lives of patients living with LVSD.
Additional Content:
The Mid Ulster GP Federation plan to produce a poster presentation to be presented at Northern Ireland Healthcare awards in April 2026 and are willing to share it with Novartis.
References:
FA-11673097 | May 2026