Case Studies

Transforming the capacity, capability, and confidence of a multi-professional primary care workforce in Heart Failure (HF)

Across NHS settings, 80% of HF is currently diagnosed in hospital, despite 40% of patients having symptoms that should have triggered an earlier assessment. The NHS Long Term Plan ambition is that people with HF and heart valve disease will be better supported by multi-disciplinary teams (MDTs) as part of primary care networks (PCNs).


The cardiology specialist team at North Bristol Trust (NBT) identified an increase in HF referrals from GP practices across Bristol, North Somerset, and South Gloucestershire (BNSSG), whereby people with worsening HF were not optimised in primary care. North Bristol NHS Trust (NBT) and BNSSG Clinical Commissioning Group (CCG) – in partnership with Soar Beyond – invited GP practices across BNSSG to express interest in a structured HF training programme as a proof of concept.


Project to demonstrate that with a consistent competency framework and tailored training and mentorship programme, 30 clinicians across BNSSG can conduct effective HF reviews in practice. The multi-professional programme, which runs from March to August 2022, aims to help aspiring clinicians improve their competence and confidence to provide high quality care to people with HF and expand HF expertise and competence in primary care to alleviate referrals into secondary care, and to improve the early detection of HF at scale. The aim was to do so in a multi-professional way utilising both primary care nurses and primary care pharmacists to deliver primary care heart failure management to the same competence framework in HF.

Solution and impact

In March 2022, Soar Beyond’s 4DTM pathway methodology was strategically adopted to utilise the SMART platform to Diagnose the competence of the 30 clinicians against a standardised multiprotection competency framework. This framework was co-produced by Soar Beyond and NBT. Three multiprotection mentors were also onboarded onto SMART.

initial stage was to develop and a agree a set of competencies for nurses and pharmacists in HF for nurses and pharmacists to develop towards with both nurses and pharmacist mentors who could then use SMART to support, develop and sign off competencies. Alongside four blended workshops (two face-to-face and two virtual) during March-July 2022, each of the 30 clinicians received one-to-one sessions with their mentors on SMART whereby individualised capability reviews and development plans were generated using the platform’s capability mapping functionality. Furthermore, Soar Beyond’s project lead analysed SMART’s capability map for the cohort as a whole to identify common gaps in knowledge and / or skills. The capability map data helped shape the content of the workshops by targeting these gaps.

  • Systematically set and assess the competencies of multi-professional roles (namely pharmacists and nurses in this programme)
  • Digitally map the capability using the competency assessment tools
  • Captures and visualises workforce capability
  • Develops and helps retain multidisciplinary teams
  • Keeps teams growing their scope of competence and support the NHS mentors
  • Supporting remote training and development
  • Monitoring Key Performance Indicators (KPIs)
  • Project management reporting by team / organisation
  • Online platform to manage, develop and retain workforce
  • Targeted training and mentorship programme
Key figures
  • 30 clinicians across BNSSG to conduct effective HF reviews in practice- both nurses and pharmacists
  • 4 targeted training workshops conducted in 4 months
  • Shift in clinicians’ confidence and competence to improve the management and optimisation of people with HF
  • Increase in QOF recorded HF prevalence
  • Code-cleansing to reduce the number of people potentially missed off QOF HF register (i.e. those with non-QOF, LVSD or rEF codes)
  • Reduction in number of people who are potentially undiagnosed or missing code
  • Increase in recorded functional capacity (NYHA classification)
  • Prescribing and initiation of medicines in primary care that would usually require secondary care / specialist initiations
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SMART – Competency Improvement and Assurance for GP Pharmacists Northern Ireland National Programme

Northern Ireland has a national programme of GP Pharmacists (GPPs) commissioned by the national department of health covering 17 federations and managed centrally.


The national programme needed to provide assurance to each of the 17 federations that the 350 GP Pharmacists were working safely and competently and to the same standard framework. The line management of these teams was extremely manual, burdensome and variable form line manager to line manager.  The national programme also needed to report on the impact of the GPP role at national, federation and practice level.


To enable the safe growth and retention of the GPPs across Northern Ireland and demonstrate the value of the role on patient care. To ensure that all 35 line managers were line managing their teams consistently, effectively and productively.

Solution and impact

The national programme has been commissioning SMART since Nov 2019 and has been utilising it for supporting the development and performance management of their workforce. The tool is used in every practice across Northern Ireland and by every GPP line manager

  • Easy to use competency assessment framework
  • Development planning and performance management tools
  • Keeps teams focused and motivated
  • Supporting remote training and development
  • Monitoring Key Performance Indicators (KPIs)
  • Project management reporting by team / organisation
  • SMART provides a repository of tools for NI which are all centralised and standardised
  • Annual appraisals and all 1:1 logs
  • Leadership matrix to develop the line managers themselves
Key figures
  • Successful national deployment and roll-out to all 350 users in November 2019
  • Cascade roll-outow-out model of line managers upskilling the pharmacists to provide scalability
  • 100% of GPPs and line managers have personalised development plans
  • Commissioned for three years


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Transforming the Atrial Fibrillation (AF) pathway to deliver better detection and protection outcomes

Quality and Outcomes Framework (QOF) data for 2017/2018 has shown that there are expected to be 6101 people with AF in Hillingdon. However, there are only 4683 patients on GP AF registers indicating potentially 1418 undiagnosed people are not receiving the appropriate stroke prevention treatment. In 2017/2018, there were 61 strokes in patients with known AF in Hillingdon, and 41% of these patients were not anticoagulated. The pan-London AF toolkit recommends that 80% of AF patients should be anticoagulated without exceptions. Hillingdon has fallen short of this treatment target as only 30 out of the 46 GP practices were above the 80% rate.
Capture AF is an award-winning AF detection and protection service in Hillingdon whereby community pharmacies identify people with possible AF using a KardiaMobile electrocardiogram (ECG) monitor and refer them to the Arrhythmia Care Team (ACT) at Harefield Hospital for diagnosis and treatment. With increasing referrals from pharmacies to Harefield Hospital, the ACT identified a need to embed routine AF diagnostics and management in primary care to free up secondary care capacity for more complex, atypical AF cases.
To establish a pharmacist-led Primary Care AF Hub in Hillingdon with the aim of:
  • Developing and expanding AF expertise in primary care to alleviate referrals to the ACT
  • Diagnosing and treating people referred from community pharmacy to the Hub
  • Carrying out opportunistic AF detection at scale during mass vaccination / long term condition clinics in GP practices
  • Improving protection and perfection of people with existing AF
Soar Beyond and the ACT at Harefield Hospital co-developed a multi-professional competency framework, which was ratified by the North West London AF Working Group in June 2022. In July 2022, Soar Beyond’s SMART platform will be used to baseline the competence of two primary care pharmacists against the standardised multi-professional AF competency framework. The process of competency assessment will involve onboarding the clinicians onto the SMART platform where they self-assess their competence against the framework. Two multi-professional mentors (arrythmia specialist pharmacist and GP with special interest in cardiology) will also be onboarded onto SMART. Each participant will self-assess their ‘Circle of Competence’ on SMART, which will highlight their AF training and development needs and define targets for the two primary care pharmacists in terms of competency development. The individual competency assessments will be analysed and themed using the SMART platform capability map function and this will inform a robust curriculum to reflect the collective training needs and skill gaps. Alongside 50 case-based discussions, each clinician will receive one-to-one sessions with their mentors on SMART whereby individualised capability reviews and development plans will be generated and designed to meet individual development needs.
Anticipated impact
  • Increase the detection of previously undiagnosed, often asymptomatic AF
  • Increase anticoagulation in high-risk people, potentially reducing the incidence of strokes
  • Initiate rate control by the appropriate prescribing of anti-arrhythmic medications potentially reducing the incidence of AF-related tachycardia-induced cardiomyopathy
  • Improve clinicians’ understanding of options for rhythm control
  • Review QOF AF registers to improve quality of monitoring and reviews
  • Improve clinicians’ understanding of when to refer to secondary care
  • Alleviate referrals to secondary care
  • Improve participant knowledge, understanding of their medications and adherence to treatment
  • Allow clinicians to develop clinical skills facilitating the expansion of their current roles while supporting continuing professional development
  • Allow clinicians to establish links with community pharmacy and secondary care teams to provide more holistic, integrated care
SMART is a web-based platform that helps healthcare organisations to:
  • Systematically set and assess the competencies of the pharmacists within the hub-setting
  • Digitally map their MDT capability using the competency assessment tools
  • Capture and visualise workforce capability
  • Develop and grow competence of the pharmacists within the hub safely
  • Supporting blended virtual and face-to-face training and development
  • Monitoring bespoke Key Performance Indicators (KPIs)
  • Standardised project management reporting by team / organisation
  • Online platform to manage, develop and retain workforce
  • Targeted cross-sector training and mentorship
“I was really excited to be provided a detailed description of the SMART platform. Now I understand the process for mapping an individual’s development via a competency-based assessment within a defined clinical field. This will be an integral part of ensuring baseline knowledge and skills are ascertained and thereby understanding the bespoke training needs for each individual. Designing a collective training package around these themes will ensure standardised training so that patients will be provided with the same level of care regardless of whom they see. Using this platform will allow me to create a robust, capable and confident workforce, that will flourish because the training has been mapped and delivered in a coherent and consistent way. I am excited that I am able to support them individually and as a group in this learning journey using the SMART platform. Importantly we will be able to use the platform to demonstrate the impact of our training interventions within the wider multi-disciplinary team.” Zainab Khanbhai Senior cardiothoracic surgical pharmacist with a special interest in AF Royal Brompton and Harefield Hospitals  

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