A new model of care for cardio-renal-metabolic (CRM) conditions in Widnes is addressing health inequalities and is projected to yield a secondary care cost saving of £1.8 million over five years. Widnes PCN lead for heart failure, Dr Henry Chan, explains more.  

There is a strong link between health inequalities and cardiovascular disease (CVD). People living in England's most deprived areas are almost four times more likely to die prematurely from CVD than those in the least deprived areas.

Widnes is an ex-industrial town where CVD is the second biggest cause of death. With its eight GP practices and a GP federation, Widnes PCN covers the entire town and serves a population of just under 70,000, putting us in a strong position to address this challenge as a group of practices working together for the benefit of our patients.

We focused our efforts on cardio-renal-metabolic (CRM) conditions - heart failure, type 2 diabetes (T2D), and chronic kidney disease (CKD) - which are closely associated with increased CVD risk.

Alongside fulfilling PCN DES contractual requirements and aligning with the Cheshire & Merseyside Cardiac Board Heart Failure Pathway (2021), this initiative aimed to bring care closer to home and help us tackle some of the health inequalities in our area.

Aim

The goal was to redesign CRM care delivery using a quality improvement approach. We aimed for collaboration across primary, community, and secondary care teams, as well as non-NHS partners.

We hoped that proactive identification of heart failure and CRM patients would improve disease register accuracy, increase therapy optimisation and lead to better outcomes – that is, fewer hospital admissions and reduced cardiovascular deaths.

As the PCN has limited resources, gaining support was essential. This was a collaborative working project between Widnes Highfield Health GP Federation, Widnes PCN, and Boehringer Ingelheim.

The project was spearheaded by me, Dr Henry Chan - a GP WA8 Collaborate Widnes PCN lead for heart failure - and Melanie Connell, Widnes Highfield Health GP director of operations and performance at the GP federation, together with PCN diabetes lead, Dr Nigel Guest. Director of transformation at the federation, Gina Lawrence, led the joint working partnership with pharmaceutical company Boehringer Ingelheim, which helped resource the project.  Third parties, such as Inspira Health and The Care Lab, were also brought in to help.

Recognising the need for a whole-system approach, we involved local NHS trusts, the voluntary sector, commissioners, public health teams and all eight practice teams from the outset.

Approach

To achieve change, we broke the programme into three phases.

Phase one was about mapping the journey. We began by looking at existing services, reviewing specifications across the system, activity levels, and patient outcomes data.

Thanks to Boehringer Ingelheim resources, we were able to explore inherent structural challenges and systemic inequalities via The Care Lab. Its participatory and insights-driven methodology - Local Carepath Optimisation (LCO) - involved co-creation workshops with patients, carers and healthcare professionals.  This collaborative process helped surface and address systemic barriers early on.

Phase two was about data insight. This involved case finding so we could understand the data through the population to get a true sense of diagnostic needs.

Inspira Health conducted additional clinical reviews to achieve this. Patients were seen in practices by local consultant cardiologists and nephrologists, enabling optimisation of guideline-directed medical therapy (GDMT). 

It also helped identify workforce requirements so that we could take a multi-disciplinary team (MDT) approach. Over 400 hours of training were delivered to primary care and community heart failure nurse teams through protected learning time sessions.

The third phase was the delivery of a new clinical model. We launched a multidisciplinary ‘hub-based’ one-stop clinic initially for heart failure, which was approved by ICB commissioners with dedicated support from hospital consultants, ensuring specialist input is available. This model provides run through same-day appointments for echocardiogram, cardiologist, specialist heart failure nurse and PCN clinical pharmacists. It ensures diagnosis and care planning happens close to home and within 2-6 weeks as suggested by NICE guidance for new suspected chronic heart failure.

Quality improvement work started in October 2023 and the first clinic at the hub was on 15th May 2025.

How it works

Patients receive a holistic review with the onsite echocardiography and consultant cardiologist meaning a diagnosis is often reached within 90 minutes. Together with the heart failure specialist nurse, a tailored care plan is created with follow-up appointments coming later.

Public health lifestyle advisors and social prescribers are available to support patients and information about local charities and patient support groups is readily available.  

Point of care testing has been embedded within each Widnes GP practice with NT-pro BNP machines provided by Lumira, and equipment funded by the PCN, to speed up the diagnostic process and ensure the right patients are referred to the hub. A rapid titration protocol has been developed for community heart failure nurses, streamlining care outside of hospital, while allowing the patient to achieve medical optimisation as soon as possible. This protocol aims to reduce secondary care admissions for patients and prevent further deterioration of their heart failure.

Outcomes

To date, 13,327 patient records have been audited and 1,425 patients reviewed. With the new hub now up and running, we aim to see a further 720 patients over the course of the pilot year. The pilot runs for one year, ending July 2026.  

The disease prevalence for CRM increased as a result of case finding:

  • Heart failure: 858 (1.3%) - 1,020 (1.5%)
  • Type 2 diabetes: unchanged at 4,283 (6.3%)
  • Chronic kidney disease: 2,249 (3.3%) - 3,366 (4.9%)

This represents a significant increase in both heart failure and CKD prevalence.

Treatment optimisation results:

  • HF patients on GDMT increased from 74% to 88% (p<0.001)
  • T2D - 512 patients had lifestyle, dietary and/or medication changes, improving glycaemic control by 5% (p<0.05)
  • CKD medications were optimised in 251 patients

Quality of life scores for heart failure patients rose from 73% to 78% post-intervention.

Using diagnostic technology - the point of care NT-proBNP machines – and increasing clinician awareness through an education programme in primary care has reduced the average wait time for HF diagnosis from 33 weeks to eight weeks. The number of patients diagnosed with HF via admission to A+E has also dropped from 48% to 33%.

Future

Using a five-year estimate, the programme is expected to reduce mortality by 125 lives and avoid 691 hospital admissions, with a projected secondary care cost saving of £1.8 million.

And with the new clinical model, patient travel is expected to reduce by 27,722 miles annually, saving 1,662 hours and cutting 5.9 tonnes of CO₂ emissions.

Widnes PCN’s care model has improved speed of diagnosis, reduced late presentations, and enhanced outcomes for our patients with new suspected heart failure. We have addressed health inequalities by engaging patients and seen improved initial diagnoses rates. Closer working between primary and secondary care has ensured efficient use of resources. 

We’ve also developed a patient education programme that offers a blueprint for future neighbourhood-based care models. Inspira Health’s offer has been shared with other Cheshire & Merseyside PCNs for wider adoption.

We are now replicating this work for patients with CKD again using a data driven and collaboration working framework to integrate CKD management into our hub model of care.