The challenge

In September 2023, we were approached by Abbey Surgery, Tavistock, for expert support to improve practice performance against the heart failure pathway.

The fundamental aim was to prevent avoidable hospital attendances and improve patient health outcomes and experience, against a backdrop of capacity challenges faced by the practice. This would be achieved by ensuring more proactive measures for the better management and monitoring of patients diagnosed with heart failure.

Our response

We designed and led a structured review of all patients on the practice’s heart failure register. Using Optum (formerly EMIS) recall searches, we identified patients who were overdue or due for review and booked appointments with them.

Our reviews were completed with the patient virtually and included an assessment of functional capacity, such as exercise tolerance, breathlessness, and activity levels, as well as heart failure medications to ensure optimisation. Where necessary, patients were flagged for follow-up by their clinician, or referred to heart failure services, ensuring timely clinical intervention.

The impact

As well as achieving our aim of improving health outcomes and patient satisfaction, our work demonstrated the value of integrating clinical pharmacists into long-term condition pathway management. With pharmacists leading structured heart failure reviews, the practice was able to maximise clinical capacity, ensure timely interventions and deliver high-quality, guideline-based care whilst reducing pressure on GP workload.

Our involvement started in 2023, with the most significant improvement seen over a six-month period, from September 2024 to March 2025, where the percentage of patients on the heart failure register who had received appropriate reviews rose by 30% to 94%. Our work enabled Abbey Surgery to exceed its Quality Outcomes Framework (QOF) target (HF007) for 2024/2025 by 4%.

Client feedback

“We have found Agentis Healthcare very good in their ability to listen and understand what we need, with the flexibility to change course when asked. They worked with us to continually develop the service, with regular reviews on performance and understanding to learn how we can further improve.”

Practice Manager, Abbey Surgery, Tavistock