Vale of Evesham Primary Care Network
Delivered comprehensive CEIF and CVD QOF project work across seven EMIS practices, achieving 100% of key targets through focused SMRs, CVD risk management, and largescale medicines optimisation initiatives.
By deploying two dedicated FTE PCN pharmacists through TMMT on a sustained 75-hour/ week schedule, the PCN delivered 150 reviews per week, hit the target on time, and achieved the upper threshold across all SMR categories without disrupting routine clinical operations.
Clinical Interventions
SMRs Completed
CEIF Targets Achieved
CVD QOF Achievement
Patient Population
Worked Across GP Practices
Key Learning Points
This case study demonstrates:
Problem
Vale of Evesham Health PCN serves a substantial population of approximately 62,500 patients across 7 EMIS GP practices in the Herefordshire and Worcestershire region. As primary care continues to evolve with increasing quality and financial pressures, the PCN faced multiple interconnected challenges that threatened both patient outcomes and practice sustainability.
The PCN was confronted with ambitious targets across several critical domains:
Without dedicated pharmacist capacity, the PCN faced significant barriers. Existing GP and nursing staff were already stretched with routine clinical workload and could not absorb the additional requirement for systematic patient reviews. The complexity of managing multiple therapeutic areas simultaneously required specialist pharmacist expertise that was notavailable within current staffing. Coordinating consistent service delivery across 7 separate GP practices with different operational workflows presented logistical challenges.
Most critically, patients were at risk of suboptimal medication management, uncontrolled cardiovascular risk factors, and preventable medication-related adverse events. The PCN recognised that without additional pharmacist support, they would struggle to deliver the comprehensive, proactive care their patient population needed while simultaneously meeting contractual and quality obligations.
Challenge
The PCN needed to deliver a comprehensive, multi-faceted clinical program encompassing several distinct but interconnected workstreams, all requiring completion within a defined timeframe to meet NHS contractual deadlines.
Key Challenges:
Additional operational challenges included: multi-practice coordination across 7 different EMIS GP practices with varying operational procedures; resource constraints as existing practice teams lacked pharmacist capacity; target interdependencies where many targets overlapped; maintaining quality standards; and deadline pressure as CEIF and QOF submission deadlines meant all work had to be completed by specific dates with no scope for extensions. The fundamental challenge was achieving 100% target completion across all domains while maintaining high clinical quality.
Solution
The Medicines Management Team provided Vale of Evesham Health PCN with comprehensive pharmacist support designed to address all target areas simultaneously while ensuring clinical quality and practice sustainability.
Service Delivery Model:
Clinical Coverage:
The Medicines Management Team’s pharmacists delivered comprehensive interventions across all required therapeutic areas:
Delivery Timeline and Progress:
6-Month Progress: Cumulative Clinical Interventions
The consistent delivery model ensured steady, sustainable progress throughout the entire project period, reaching all targets on schedule without creating workflow bottlenecks for practice staff.
Target Achievement:
The TMMT pharmacist team achieved 100% completion across all five major target categories: CEIF Targets, CVD QOF Targets, CHOL003 Target, QRISK >20% Target, and Hypertension QOF Target.
Outcomes Achieved:
Outcomes Achieved:
The partnership between TMMT and South Worcs Vale of Evesham Health PCN delivered exceptional outcomes that exceeded initial expectations. By achieving 100% completion across all CEIF and CVD QOF targets, the PCN secured maximum available income while simultaneously delivering genuine clinical value to over 2,050 patients.
The systematic approach to medication optimisation and cardiovascular risk management has created lasting benefits for the patient population. The 1,000+ elderly patients who received comprehensive structured medication reviews now benefit from safer, more appropriate prescribing, with reduced risks of adverse drug events and unnecessary polypharmacy. The focus on cardiovascular disease prevention through optimal cholesterol management, blood pressure control, and diabetic care will prevent heart attacks, strokes, and other cardiovascular events in the years ahead.
Critically, the TMMT model allowed the PCN to achieve these ambitious targets without overwhelming existing practice staff or disrupting routine clinical services. By providing dedicated pharmacist expertise exactly when and where it was\ needed, TMMT enabled the practice teams to maintain focus on their core clinical responsibilities while still exceeding all contractual and quality requirements.
For the individual patients impacted by this program, the benefits are tangible and significant. Elderly patients on multiple medications now have safer, more streamlined prescribing regimens. Patients with high cardiovascular risk have been identified and are receiving optimal preventative treatment. Those with diabetes, hypertension, or high cholesterol have had their therapy optimised based on current evidence and guidelines. Hundreds of patients who were taking medications that were no longer appropriate such as long-term melatonin or unnecessary iron supplements have had these safely
reviewed and adjusted.
From a practice sustainability perspective, the partnership demonstrates how PCNs can successfully navigate the increasingly complex landscape of primary care contracts and quality frameworks. The 100% achievement across multiple target domains has secured maximum available income from CEIF and QOF, providing financial stability that supports ongoing service delivery. Equally important, the PCN has strengthened its reputation for quality and patient safety, positioning it favorably for future contract negotiations and quality initiatives.
This case study proves that quality and efficiency are not competing priorities but mutually reinforcing goals. With the right support model dedicated pharmacist expertise deployed strategically across multiple practices PCNs can simultaneously achieve financial sustainability, clinical excellence, and meaningful patient outcomes. The success of this partnership shows that targeted specialist resources, properly deployed, create value that far exceeds their cost through improved patient care, enhanced practice reputation, and secured income streams.
The model established here is scalable and replicable. Other PCNs facing similar challenges in meeting CEIF and QOF targets while managing complex patient populations can adopt this approach, confident that dedicated pharmacist support delivers measurable, demonstrable outcomes across all key domains: patient safety, clinical quality, financial performance, and operational sustainability.
Looking forward, this partnership has established a foundation for ongoing collaboration. The systems, protocols, and working relationships developed during this project create a platform for future quality improvement initiatives. The PC now has proven experience in deploying specialist pharmacist resources effectively, and TMMT has demonstrated the ability to deliver complex, multi-practice programs to the highest standards. This positions both organisations to tackle future challenges—whether new contractual requirements, emerging clinical priorities, or evolving patient needs—with
confidence and capability.
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