The challenge

Heart failure is a growing challenge across the UK, including in the South West. Over one million people are living with the condition, and numbers are expected to double by 2040.  

Somerset faces higher-than-average prevalence of heart disease, significant variation in access to specialist services, and a large rural geography that makes consistent care delivery difficult. 

In the county there has been inconsistent prescribing of guideline-directed heart failure therapy, under coding and under-identification of patients, workforce pressure in primary care limiting proactive review and optimisation, and variation in clinician capability and confidence. These gaps were strongly felt by frontline clinicians.  

The solution 

In 2025/26, Somerset Integrated Care System (ICS) and Health Innovation South West delivered the Heart Failure Champion Programme to test whether an incentivised, clinically–led, primary care network (PCN) based model could strengthen heart failure management. 

Our work in partnership

Together with Somerset ICS we: 

• Appointed Heart Failure Champions across six PCNs 

• Delivered targeted clinical education, including cardiologist-led sessions 

• Provided structured implementation support, including project management and coaching 

• Improved coding accuracy, enabling more reliable patient identification 

• Identified priority patient cohorts, such as those not on SGLT2 inhibitors 

• Optimised prescribing using guideline-directed therapy 

• Captured patient experience and quality of life data. 

‘Champions’ were empowered to adapt the model to local needs.  

Our impact 

The Somerset Heart Failure Champion Programme has demonstrated that improving prescribing, clinician capability and proactive heart failure management is achievable – but dependent on local leadership, capacity, and data readiness.  

We have seen impact in Somerset across six areas:

1. Improved prescribing across all four pillars of heart failure treatment 

System-wide prescribing increased across all four pillars (ACE inhibitors, beta-blockers, SGLT2 inhibitors, and MRAs) during 2025/26, with SGLT2 inhibitors showing the most substantial growth as a result of this intervention. 

We are the third ranked PCN in the ICB for SGLT2 treatment in heart failure. I think that’s a massive win in such a short space of time.

Heart Failure Champion 

2. Increased clinician capability and confidence 

Clinicians consistently reported improved confidence in discussing and initiating therapies. 

Confidence is much higher now because they know they can come and approach me for advice.

Heart Failure Champion 

3. Early symptom improvements or stability 

Kansas City Cardiomyopathy Questionnaire (KCCQ) data showed early symptom improvements for many patients, with stabilisation for others. 

4. Positive patient experience 

Patients appreciated clear communication and medication reviews. Clinical processes improved too.  

5. Improved system and operations

One site embedded a more sustainable workflow, including a recurrent coding review. 

Coding has changed… prospectively, I think coding is now fixed so we won’t have those missed cases again.”

Heart Failure Champion 

6. Sustainability and Resilience

Workforce models were strengthened and shared across teams. 

I’ve asked two other colleagues to lead on that with me… if I ever leave, they won’t feel floundered.” 

Heart Failure Champion 

A blueprint for scaling heart failure improvement

The Heart Failure Champion Programme in Somerset provides a blueprint for scaling heart failure improvement across the South West. 

Here are our recommendations for system implementation:

• Design and commission the programme as a delivery model – not just training 

  Training improved confidence, but meaningful change occurred where delivery capacity was supported quality improvement projects were designed. 

• Use a team-based approach, not a single champion 

  A small clinical team with prescribing authority enables resilience and shared ownership. 

• Start with data readiness and coding 
  
  Early coding improvements unlock accurate cohort identification. 

• Define a prioritised patient cohort early 

  Focusing on groups such as patients not on SGLT2 inhibitors enabled quick wins. 

• Align with existing services 
  
  Avoid duplication and ensure clarity when programmes operate alongside or after other related interventions. 

• Resource operational delivery 

  Coding, searches, and follow-up require protected time. 

• Build PCN-level ownership and coordination 

  Secure sustained commitment and accountability from PCN-level senior leadership to ensure PCN approach to support spread across practices.