Drive to find vulnerable groups helps 100 at risk of heart failure

Case study summary

More than 100 people discovered to be at risk of heart failure in inner city Bristol had their medication reviewed and were offered specialist appointments to help them stay well. The group was identified as part of the NHS England and NHS Improvement Population Health Management Programme to find people struggling to access the right services and offer more personalised help.


Bristol Inner City Primary Care Network in Bristol, North Somerset and South Gloucestershire Integrated Care System – a team including GPs, data analysts, public health consultants and social prescribers.

What was the aim?

This project aimed to improve the health and wellbeing of a group of people who were at higher risk of developing heart failure.

They developed short, medium and long-term aims including medication reviews, improved understanding of health conditions such as heart failure, reducing smoking rates and increasing physical activity for individuals and across the system, reducing admissions to A&E and outpatients and appointments needed in general practice.

People living in the more deprived areas of the Bristol, North Somerset and South Gloucestershire Integrated Care System are more likely to die 7.5 years earlier if they are men and 6.7 years if they are women. Overall, people living in those areas are not only on average more likely to die earlier but also have 10 fewer years of good health.

What was the solution?

The project used new ways to link and analyse data to find the high risk group then offered the patients a medication review, a healthy hearts group consultation and an appointment with a social prescriber to help with exercise, mental health and lifestyle issues.

The team assessed linked data – including general practice, acute, community, the wider determinants of health and mental health – to create a deeper analysis of people living in the area.

By using new techniques such as segmentation and risk stratification they found a large group of people in Bristol inner city with high levels of deprivation and aged 40 to 69, who also had a combination of obesity, high blood pressure, depression and anxiety.

After consulting doctors and other health and care professionals in the PCN, they decided on the best solutions to help the group including:

  • a medication review to ensure they are getting the best treatment
  • the offer of a one-hour appointment with a social prescriber – this includes time to think through any personal issues which may be affecting their health; they can be referred to other organisations for support, such as citizen’s advice for debt problems, mental health services or charities or lifestyle help with cooking and exercise
  • the Healthy Hearts group consultation programme, which almost half have been offered, meets specialists and peers to discuss health issues and find solutions.

What were the challenges?

The COVID-19 pandemic has taken priority for people’s time and energy and has made interventions more limited.

What were the results?

So far:

  • all 102 patients have been contacted and asked if they would like a visit from a social prescriber
  • 100% have had desktop reviews​​ by a clinician covering medication reviews and health checks
  • group consultations have been arranged and 42 have so far been invited; these will be held in the New Year, are fully booked, and a waiting list has been set up.

How the group’s health improves will be measured regularly over the coming weeks and months and during the person’s annual health check.

It is hoped the project will improve patients’ understanding of their health and improve their physical and mental health in ways which are important to them, particularly addressing factors affecting their health beyond healthcare. Across the system the aim is to reduce unnecessary appointments and admissions to A&E, outpatients, and general practice.

What were the learning points?

Anne Wray, an Advanced Nurse Practitioner who co-led the project for Bristol Inner City Primary Care Network, said: “We know that locally we have a number of health inequalities and this project really helped us get to the most vulnerable.

“Once the data showed us there were 102 people at high risk of developing heart failure, we were able to contact them directly and offer them the best support.

“People were very pleased to have someone reach out and try to help – it’s so motivating as a nurse to know that we can use data to actively try and help people before their health has already declined. To know we are adding many years of health to people’s lives really motivates a team, especially with the pressure the NHS is under”.

Edouard Guidon, a social prescriber on the project, said: “What this project did was put us in contact with people who hadn’t reached out to services outside of healthcare. By helping, reaching out to address the wider issues affecting their health, we’ve provided help which will hopefully prevent more complex problems in later years – be that type 2 diabetes or ultimately heart failure”.

Inspiration: health professionals involved have found it exciting to be able to identify and target help for healthcare needs to those who may not be getting it.

Efficiency: by focusing on the PCN’s current priorities – ie CVD diagnosis and prevention – the programme helped it achieve today’s goals. Using the methodology in future on DES and QOF products can help with core day-to-day work with no extra burden.

Relationships: these have formed with professionals across services, particularly with social prescribers and the wider PCN team.

Resources: the main resource required was personnel time, supported by PCN staff, practices and social prescribers.

Usability: The learning and buy-in from the development programme meant that local teams carried out PHM analysis for a number of system priority programmes during the course of the programme including:

  • COVID high risk cohort identification
  • stroke stratification
  • ReSPECT evaluation
  • COVID max vax uptake.

This systematic approach to identifying and addressing inequalities and their causes is becoming embedded in the emerging culture of the PCN, supporting an emerging model of proactive care and collaborative working at place level.

For more information on PHM please join the PHM Academy at the bottom of this page: NHS England » Population Health and the Population Health Management Programme.