CLEAR Living Well CVD Transformation Programme
Shore Medical PCN
Improving the prevention, detection and management of cardiovascular disease in Bournemouth
At a glance
The challenge
Rising demand for GP appointments and increasing cardiovascular risk created pressure on access, with gaps in screening, data coding and coordinated multidisciplinary prevention efforts.
Key changes
Redesigned prevention model using multidisciplinary teams, expanding non-GP roles, improving data coding and referral pathways, and enabling earlier intervention and ongoing cardiovascular management.
Forecast impact
Reduced GP demand, improved access to community care, fewer emergency attendances, stronger hypertension management, earlier intervention, and improved long-term outcomes alongside increased system efficiency.
The challenge
Shore Medical PCN, serving over 58,000 patients, faced growing pressure in managing cardiovascular disease (CVD), with rising demand for GP appointments and limited capacity for prevention.
Screening and identification of at-risk patients needed strengthening, alongside improvements in data coding and use of the multidisciplinary team. As a result, opportunities for earlier intervention were missed, increasing pressure on primary care and emergency services.
The approach
Commissioned through the National CLEAR Programme, the Living Well initiative supported Shore Medical PCN to redesign cardiovascular prevention using clinical insight and data analysis.
CLEAR worked with frontline teams to analyse population data, identify gaps in detection and management, and co-design a new model of care. Workshops and engagement sessions enabled clinicians to explore opportunities to improve access, capacity and outcomes.
The programme focused on earlier identification of risk, strengthening data and coding processes, and delivering care through a broader multidisciplinary team, supporting a more proactive, community-based approach to prevention.
What we recommended
- Redesign prevention pathways to support earlier identification and management of patients with hypertension and cardiovascular risk
- Shift routine activity from GP appointments to a multidisciplinary team model, increasing non-GP capacity
- Introduce structured hypertension management delivered by pharmacists and advanced nurse practitioners
- Improve data coding and population health management to strengthen patient identification and tracking
- Expand referral pathways into lifestyle and community-based support services
- Embed multidisciplinary working to support consistency and continuous improvement
Forecast impact
Implementation of this model has improved access, outcomes and system efficiency across Shore Medical PCN. GP capacity has been released, while patients benefit from earlier, community-based support.
Hypertension management has strengthened, with increased reviews and improved blood pressure control. Emergency department attendances have reduced significantly, reflecting more proactive care.
The programme demonstrates how prevention-led redesign can reduce demand, improve patient experience, and deliver an estimated £179k in annual savings.
Early, tangible change
- Reduction in GP appointments by 10.7%, freeing 3,666 sessions
- Increase in non-GP appointments, with overall activity rising by 6%
- Expansion of hypertension cohort by 9.2% through improved case-finding
- Improved access to community-based care and earlier intervention
- Significant reduction in emergency demand, with 51.5% fewer emergency attendances
Could your service be next?
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