Project Name: Service improvement for the detection and treatment of Heart Failure (“HF”) in secondary care

Project Summary:

The aim of the proposed JWP is to improve identification, monitoring, management and treatment of HF patients in secondary care via:

  • the extension of the current hospital based specialist HF service through the deployment of an “in-reach” nurse
  • with the purpose of identifying and triaging HF patients (both at acute medical receiving units and non Cardiology
  • departments) so they can be appropriately referred and receive specialist HF input;
  • the utilisation of a bespoke HF patient database (the “Database”):the Database will facilitate the identification of
  • new HF patients and the management of existing HF patients in secondary care;
  • the implementation of a Multi-Disciplinary Team (“MDT”); and
  • the increase of capacity of the current out-patient HF Specialist Clinic.

The activity of the ‘in-reach’ nurse, the proactive review of the Database by HF specialist nurses (the “HFSN”) and scrutiny by the MDT of the most complex cases will promote timely and appropriate follow-up care, which may include attendance at additional outpatient HF Specialist Clinic, based in secondary care.

Planned Milestones:

Milestone 1 (i) Agreement on design and content of Database
Milestone 1 (ii) Development of Database
Milestone 1 (iii) Deployment of Database and training of Trust staff
Milestone 2

The Trust shall procure the services of:

  • 2 x specialist HF nurses – (MDT and HF Specialist Clinics)
  • 1 x band 6 HF Nurse (in-reach nurse)
  • Lead HF Consultant (MDT , support to clinical operations as required, project management)

On-boarding and familiarisation of personnel

Complete collection of baseline comparator data for the project outcomes
Milestone 3 Development of strategies/protocols and implementation procedures
Milestone 4 (i) Clinical operations commenced and ongoing according to the developed protocols
Milestone 4 (ii) Continue clinical operations according to the developed protocols
Milestone 4 (iii) Complete final 6 months of clinical operations according to the developed protocols
Milestone 4 (iv)

Complete final 18 months of clinical operations according to the developed protocols

Analyse data and prepare business case

Milestone 5 Novartis to provide funding for one year continued use of database commencing Aug-2022 to Aug-2023 Trust to contract with third party directly, as before.
Milestone 6 Submission of business case
Milestone 7 Submission of JWP Report


Expected Benefits:


  • improved access to optimal diagnosis and treatment;
  • more equitable and consistent care and access to care;
  • enhanced experience for patients who live with HF and their carers.


  • increase the overall quality of care and improve equity of access to specialist care for patients with HF;
  • improve patient flow and reduce total number of unplanned admissions due to HF;
  • increase proportion of patients with HF being managed in accordance with NICE guideline standards;
  • insight into benefits of an enhanced HF service which may inform ongoing redesign and workforce planning.


  • further opportunities for the appropriate use of cardiology licensed medicines in line with NICE guidelines, including Novartis’s medicine;
  • improved professional and transparent relationship and trust between Novartis and the NHS.

Start Date & Duration: October 2019, 47 months

UK | July 2023 | 655325