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

Sunderland Case Study




  • Had ambitious plans to rapidly expand the workforce
  • Recognised they needed structured framework to ensure standardised delivery of the clinical pharmacist and technician role across their PCNs
  • Sought expertise from Soar Beyond to help with their vision
  • Soar Beyond commissioned to deliver 4D Accelerator sessions with senior pharmacists, enabling the use the SMART platform to quickly create a map of baseline competencies and capabilities which highlighted and identified training and development needs




Sunderland GP Alliance, a federation made up of six primary care networks, with a population size of 250,000 across 36 practices.

The federation had an ambition of recruiting and mobilising 50 pharmacists from a current team of six within a 6-month period. They recognised that it was not only important but essential to assure that there was a safe and standardised deployment when the pharmacists were coming from a range of different backgrounds and levels of experience.

If this was not done in a systematic and standardised way, it would lead to variation in quality of delivery of service across the federation, impacting patient care.




To safely grow, develop and train the pharmacy workforce and measure the impact over the contract




  • A set of competencies were created utilising the Soar Beyond Circle of Competence tool.
  • SMART was utilised to manage and assess competencies, as well as help with development planning across the team. This was done remotely due to the COVID-19 pandemic.
  • THE SMART capability mapping tool was utilised to help identify any gaps in knowledge, this resulted in the identification of growth area, management of frail and elderly patients
  • A customised training and upskilling programme was developed to help build knowledge in this area




Within 18 months of starting the process Sunderland Alliance federation developed and retained a strong and confident pharmacy team. This was seen by the:

  • Visual shift in competence on the Circle of Competence tool
  • Systematic quality improvement of clinical delivery
  • Improvement in patient outcomes for both frail and older patients

North London Productivity Case Study




  • Practice overwhelmed with prescription burden
  • Unmanageable workload -> no GP capacity to support pharmacists
  • Understood their own limitation and sought support from Soar Beyond
  • With support from a senior pharmacist and the SMART platform the practice has achieved a 50% reduction in prescription workload




Practice based in North London (11,000 list size) faced similar problems to many -workforce crisis, with the lack of GPs and nurses, and an increase in workload due to the growing demands of the population. The practice was overwhelmed with the prescription workload and decided to take on and eventually increase the pharmacist capacity within the practice to manage this. The practice went from 0.8 WTE to 2 (made up of three pharmacists) and although the process was refined, and the pharmacists led on the prescription process the workload was still unmanageable. The GPs recognised there was a mix of capability and competence between the pharmacists, and a lack of capacity from themselves to provide adequate support to train and upskill the pharmacists. There was also a sense of the pharmacists taking too long – ‘GPs used to do this much faster’ creating anxiety and dissatisfaction within the team. The practice commissioned Soar Beyond to provide them with support and structure through the SMART platform and additional supervision support through a senior Soar Beyond pharmacist.




  • Review individual pharmacist competence and create a development plan for each of them in line with the practice needs.
  • Review prescription process and implement systematic change across the practice to improve workload




  • Baseline competency assessment completed for each pharmacist focused on practice needs around prescription management
  • Detailed plan created to address prescription workload through a system review with the SMART 4D™ repeat prescribing toolkit
  • Incorporated proactive medication review and QOF reviews
  • Implemented a process to identify patients who would be suitable for eRD
  • Clarity of roles and accountabilities across the practice for each step of the prescribing process
  • Half a day a week mentoring and support provided by a senior Soar Beyond pharmacists, allowing for a focused checkpoint on progress on development plans and prescribing process




  • All pharmacists are clear on their deliverables for the practice with a clear development plan in place
  • Standardised process implemented across the practice to manage the repeat prescribing process which included clarity of roles across the practice for each step of the process.
  • All the pharmacists feel supported and valued due to the impact they have made on the prescribing process
  • The coordinated approach of developing the pharmacists and empowering them to take on the repeat prescribing process with a dedicated approach to medication review has led to a 50% reduction in prescription workload


“Soar Beyond has co-ordinated a proactive approach to support our practice to implement a pharmacist led programme, to develop a systematised repeat prescribing process including a proactive medication review & QOF process which has significantly reduced the entire practice prescription workload by 50% not only for the pharmacists but also our practice admin. team. We are now able to recommend and replicate a process across the PCN”

 Meena Thakur, Clinical Lead, East Harrow PCN

Oxfordshire Productivity Case Study




  • Practice keen to recruit but not sure where to start
  • No previous experience of working with pharmacists
  • Requested help from Soar Beyond with a 4D Strategy Workshop and recruitment support
  • Pharmacist recruited with clarity of role and deliverable’s from the start




Three practices in Didcot joined to form Didcot Primary Care Network with a patient population of over 43,000. Despite the practices being local to each other, each practice had different population needs. Although they had good informal relationships, they had no previous experience of working together in an organised way.

The practices all had:


  • similar issues regarding workload and capacity
  • a good mix of healthcare professionals and a desire to work closely to make the PCN structure successful for their staff and patients
  • a clear rationale for investing in a pharmacist with the funding available; however,


None of the practices had any previous experience of working with a pharmacist other than CCG practice-based pharmacists

There were concerns that the PCN’s lack of experience and knowledge of background, skills, and training of a clinical pharmacist could lead to common pitfalls they were hearing from other PCNs and they didn’t want to recruit the wrong candidate for their PCN needs.




The PCN needed to recruit and employ an effective pharmacist who could hit the ground running and start prescribing, running medication reviews, and delivering the income generation and clinical requirements of the directed enhanced service in an equitable way across the three practices. PCN staff sought external expertise from Soar Beyond, to accelerate the process and guide them.




Soar Beyond ran a facilitated diagnostic session in July 2019 with participation across the three practices. This session helped staff to:


  • understand what the practice pharmacist can do and how they would add value
  • collate the needs of the individual and collective practices, and manage practice expectations
  • identify the specific skillset of the clinical pharmacist they wanted to recruit. Staff decided that the candidate needed the leadership skills to work autonomously so that they would require less intensive support.


The PCN therefore sought a more senior pharmacist with an existing independent prescriber qualification and relevant experience to support and drive the PCN agenda, even though this would require additional ‘top-up funding’ by the practices. Staff outsourced the recruitment and support to Soar Beyond to ensure they would find the right candidate.

Soar Beyond supported the practice by:


  • advertising to attract a clinical pharmacist with the right skillset, as well as screening and testing candidates for fit with the defined criteria
  • designing and leading a rigorous needs-based interview with GP participation
  • helping the PCN to sell the role to potential pharmacist candidates
  • supporting the PCN to employ and agree suitable terms and conditions.




After a thorough screening and interview process, a suitably experienced candidate was interviewed in September 2019 with an offer made to start work in January 2020. The delay in start date was due to a lengthy notice period, which is typical for skilled professionals—something that should be considered when beginning recruitment.

The benefits for the PCN, practices, and pharmacist included:


  • clarity of expectations and deliverables among practice staff
  • a clear and structured 90-day induction plan with agreed KPIs aligned to the PCN’s needs and priorities, such as streamlining the repeat prescribing process across practices
  • a structured development plan aligned to PCN’s goals and to the pharmacist’s existing competencies
  • a supported pharmacist, without the practice being overburdened, who is well placed to upskill the remainder of the clinical and non-clinical team members
  • access to the Soar Beyond SMART platform, which includes a suite of online resource, toolkits, and other implementation resources to enable the pharmacists to roll out new processes efficiently and effectively, without having to ’reinvent the wheel’.


The PCN has commissioned additional senior pharmacist support from Soar Beyond to provide regular coaching calls to ensure development and progress is kept on track through KPI reporting and deployment of milestones.




Although the whole process took 6 months, this was accelerated using external support and expertise, and prevented Didcot PCN encountering common pitfalls experienced by other PCNs, such as taking on inadequately experienced pharmacists or those that require significant support and supervision.

‘Working through the recruitment and induction process with the support of Soar Beyond has been strategically invaluable in terms of aligning my vision and values with those of the PCN Clinical Director and member practices. In my experience so far, this very alignment is crucial in effectively delivering the PCN Pharmacist role at scale.’ 

Ziad A Laklouk; PCN Pharmacist, Didcot PCN

South East Oxford PCN Pharmacy Team Strategy




  • PCN keen to grow pharmacy team
  • Struggled to recruit following two rounds of recruitment activities
  • Requested a consultation and demo from Soar Beyond
  • Vision and strategy in development and recruitment underway with one post already filled


“We requested a consultation and demo from Soar Beyond and we immediately saw how they could help. Through their support I could see we could bring the PCN together to have a shared vision of what the pharmacy team could deliver to improve workload and capacity for the clinical team but to also improve standards and patient care.


We initially commissioned them to support with recruitment and the 4D Strategy Workshops but subsequently also took on the SMART platform to enable and empower our senior pharmacist to take a lead on service delivery. With KPI monitoring and development planning modules it would support the pharmacists regardless of previous background and training ensuring a standardised approached to delivery.


We have so far successfully recruited one pharmacist and Soar Beyond are working hard to fill the other two roles to meet this years target. We are in the early days of using the platform but the initial strategy session has provided focus and we are looking forward to the second in the series.”

Dr Kathryn Brown

GP and PCN Clinical Director, South East Oxford Health Alliance PCN