Prevention programme helps identify more at-risk residents and support earlier care 

A Wirral primary care network serving around 60,000 people is reporting early improvements in patient care and reduced hospital admissions, following the introduction of a new approach focused on prevention and earlier support. Moreton & Meols and Wallasey Wellbeing Primary Care Network (PCN), part of NHS Cheshire & Merseyside, has been working to identify residents at higher risk of heart disease and related conditions earlier through the CLEAR Living Well programme, helping to tackle longstanding health inequalities across the area. 

The programme has focused on reaching people who may previously not have been identified or engaged with services. In its first year, the number of patients receiving personalised support increased by 18.1 percent. This includes a 35 percent increase in people identified with high blood pressure, a 23 percent increase in those with cholesterol issues and an approximate 18 percent increase in patients living with obesity. There has also been a 38 percent rise in patients identified with high alcohol intake and a 4.4 percent increase in identified smokers, alongside a higher proportion of people who have successfully stopped smoking. 

There are also early signs of improved health outcomes. The number of patients with blood pressure under control has increased by 17 percent, while unplanned hospital admissions have reduced by 10 percent. Preventative care has expanded, with around 39 percent more NHS Health Checks carried out across the network. Changes in how care is delivered are also emerging, including a small reduction in overall appointments, alongside a 4.5 percent increase in GP appointments, helping ensure patients with the greatest need receive appropriate clinical support. 

Rachel Voller, ANP Lead Nurse for Innovation at Moreton & Meols and Wallasey Wellbeing Primary Care Networks  said: 

“We see every day how conditions such as high blood pressure, raised cholesterol and irregular heart rhythms can affect the lives of our patients and their families when they go undetected. Through our Healthy Hearts programme, we are now reaching more patients at risk, supporting earlier diagnosis and intervention, and creating opportunities for better long-term health outcomes across our neighbourhoods.” 

Heart and circulatory disease affects millions of people across the UK and is a leading cause of early death, particularly in more deprived communities. In Wirral, over a third of residents live in some of the most deprived areas in England, and there can be a significant gap in life expectancy between communities. The CLEAR Living Well programme, commissioned by NHS England, supports GP practices to work together to improve prevention, make better use of their teams and provide more personalised care. Now being used in over 90 primary care networks across England, the approach aims to help local areas deliver more consistent, proactive care tailored to their populations.