Establishing a data led approach to service redesign for patients living with (diagnosed and undiagnosed) heart failure (HF), chronic kidney disease (CKD) and Type 2 Diabetes (T2D), across Widnes Primary Care Network (PCN).

A Joint Working project between Boehringer Ingelheim Limited (BIL) and Widnes Highfield Health GP Federation to deliver service redesign, acknowledging the complex interplay between chronic kidney disease (CKD), type 2 diabetes (T2D), and cardiovascular disease (CVD), our initiative will underscore the importance of comprehensive care strategies that prevent and address these conditions. By harnessing the power of real-world data, our goal is to drive improvements in diagnostic and service delivery, ensuring holistic and equitable access to enhance patient outcomes.

The key objectives of this project are to

Build on the Action Framework created as part of a collaboration between BI and Cheshire and Merseyside in 2022 to create an integrated Cardio Renal Metabolism (CRM) service blueprint, close to the patients within the PCN.

Understand and plan for future service provision through the implementation of a comprehensive CRM quality improvement programme with a focus on:

• Creating a multi-layered approach to raise CRM awareness and drive detection.
• Develop neighbourhood proximity to services to facilitate equitable access to testing and specialist care ensuring quicker access to appropriate assessment, diagnosis and replace with a treatment plan as appropriate.
• Drive impactful change to enhance patient wellbeing and cultivate an integrated, supportive working environment for NHS colleagues.
• Develop a model of care that can be used as a blueprint for other Long-Term Conditions in Widnes and neighbouring localities within Cheshire and Merseyside Integrated Care System.
• Continued collaborative and creative engagement with diverse stakeholders from across the integrated healthcare system to transform care pathways.
• Project management mentorship to achieve future integrated care pathways.

Widnes Highfield Health GP Federation are committed to improve their understanding of the challenges related to the delivery of care for citizens with CRM and collectively address changes needed for effective management across the health and care system. They plan to adopt the service redesign into operational strategies to unify healthcare services making this collaboration a model for advanced integration.

This project aims to mobilise resources for a period of 14 months from October 2023 until January 2025.

Boehringer Ingelheim Limited is pleased to collaborate with Widnes Highfield Health GP Federation (and affiliated partners) to design and deliver this Collaborative Working Project.

Completed Outcomes:

The project has successfully delivered the key objectives of implementing a comprehensive CRM quality improvement programme and creating an integrated Cardio Renal Metabolism (CRM) service blueprint.

The benefits realised by this collaboration are:

• Education for healthcare professionals and patients.
• MDT delivery for HF nurses and GPs.
• Increased CRM patient list size from 6,190 (9.1%) to 6,871(10.1%) across Widnes PCN.
• 19% increase in patients coded with HF, 42% increase in patients coded with CKD.
• 1,425 patients reviewed by Cardiologists / Nephrologist.
• Change in the diagnosis location of patients with HF with 48% identified in A&E prior to the project compared to 33% after phase 1.
• The proportion of HF patients on Guideline Directed Medical Therapies increased from 74% to 88% post-review (p<0.001).
• In T2D, 512 patients improved glycaemic control by 5%, while 251 CKD patients had their medications optimized.
• Improvement in patient quality of life increasing from 73% prior to interventions to 78%.
• These changes have led to a reduction in the carbon footprint across Widnes with a reduction in CO2 emissions equivalent of planting 236 oak trees.

This project also co-created a Cardio-Renal-Metabolic (CRM) integrated neighbourhood service model to support the population living with long-term conditions in Widnes going forward.

This will be implemented and evaluated over the coming year as part of a further Joint Working Project with Boehringer Ingelheim.

NP-GB-105771 April 2025

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