Leatherhead Primary Care Network (PCN) Joint Working Summary | Boehringer Ingelheim UK
Implementing a community-based heart failure clinic to optimise the care and holistic management of symptomatic patients with chronic heart failure across Leatherhead Primary Care Network (PCN).
The Leatherhead Primary Care Network (PCN), in partnership with Boehringer Ingelheim Ltd (BIL), launched a community-based Heart Failure (HF) clinic from May 2024 to June 2025 to address critical gaps in the management of chronic heart failure. The initiative aimed to improve patient outcomes, reduce hospital admissions, and enhance the capacity of primary care services.
Key drivers for the project included long wait times for cardiology services, inconsistent HF care across practices, and poor clinical coding impacting both patient care and financial reimbursement. The project introduced a structured, PCN-wide HF review service delivered by a GP with a special interest in cardiology and a clinical pharmacist. This model standardised care across four practices, improved clinical coding, and optimised medication management.
Key Outcomes:
- 268 patients were reviewed, with significant improvements in the quality and completeness of HF reviews.
- Heart failure prevalence increased by 0.28% (123 patients)
- Medication optimisation improved, with 101 additional patients receiving all four pillars of HF therapy.
- Emergency department attendances for HF dropped from 10 to 1 in the 30 weeks post-intervention.
- Primary care appointments decreased by 9% post-review, compared to a 25% increase in the control group.
- Patient satisfaction was high, with 98.3% of respondents rating the service as good or very good.
Recommendations:
- Standardise HF review protocols across practices.
- Enhance clinical coding to improve data quality and financial outcomes.
- Improve communication with secondary care to support accurate diagnosis and coding.
- Leverage financial efficiencies by reducing unnecessary outpatient appointments.
- Replicate the model for other long-term conditions such as diabetes and chronic kidney disease.
- Upskill the primary care workforce through regular HF education and training.
The project demonstrates the value of integrated, community-based HF care and provides a scalable model for improving chronic disease management across primary care networks.
NP-GB-106116 July 2025