Proactive Care for Heart Failure in Neighbourhoods

This innovative pilot was developed in response to rising emergency admissions and fragmented support for patients with long term conditions across Surrey Downs Place, with particular focus on the Winter period and beyond, when system pressures are at their highest. Patients with heart failure often present with one or more co-morbidities, which increases vulnerability and heightens reliance on acute services, particularly during winter months when conditions can exacerbate symptoms and trigger deterioration. Further to this, Surrey Downs was identified as an outlier in heart failure attendances at Accident & Emergency (A&E) in a recent national report. By using population health management tools, we were able to proactively identify high risk patients for tailored support.

The pilot adopted a proactive, population health-driven approach. High-risk patient groups, based on risk of deterioration, emergency department attendances and hospital admissions were identified using PHM tools, then prioritised for structured, holistic assessments and personalised care plans. Seven Integrated Neighbourhood Teams (INTs) delivered interventions, supported by multidisciplinary team (MDT) meetings and clear escalation pathways to specialist services. This proactive model was linked with the specialist MDTs and urgent care services such as virtual ward or Urgent Care Response Service to ensure a complete end to end pathway. Care delivery was co-designed by clinicians and carers across INTs and front-line staff received targeted training.

The programme delivered significant improvements in care for Surrey Downs patients with long-term conditions. From 2939 Heart Failure patients identified via population health risk stratification, 470 patients were selected for structured interventions which resulted in 1266 appointments carried out in their local neighbourhoods over a seven-month period.

Key findings revealed that holistic assessments and personalised care plans led to better patient engagement, improved self-management, and enhanced coordination across health and social care services. Patients reported feeling more supported and empowered, with many experiencing improved quality of life and reduced anxiety around managing their conditions.

From a system perspective, the pilot contributed to a measurable reduction in emergency admissions and avoidable hospital attendances. Early data suggests a positive trend in reduced demand on urgent care services (Patients who went through the programme had 50 fewer A&E attendances), indicating that proactive, integrated care can alleviate pressure on overstretched systems.

The impact extended beyond individual outcomes. Multidisciplinary collaboration across teams and partner organisations was strengthened, with primary care, community services, and voluntary sector partners working more cohesively and delivering a single plan for each individual patient. This encouraged a more sustainable model of care, built around prevention and personalised support.

The pilot which is aligned with NHS England health policy of shifting from sickness to prevention, demonstrated that using data-driven approaches to identify and support vulnerable patients can lead to meaningful improvements in health outcomes, patient experience, and system efficiency. These findings provide a strong foundation for scaling the proactive model for long term conditions through neighbourhoods across other areas, with the potential to transform care for people with complex needs.