How The Medicines Management Team Helped Vale of Evesham PCN Achieve 100% CEIF and CVD QOF Targets

What if the difference between “good enough” and “perfect” in primary care came down to just one decision? Imagine a scenario where every single clinical target is not only met, but exceeded; where 2,000+ patients receive tailored interventions, and even the most vulnerable are safer than ever before.

Sounds impossible? That’s exactly what most people thought, until The Medicines Management Team partnered with Vale of Evesham PCN.

How did a single team help seven busy GP practices smash every CEIF and CVD QOF target, safeguard elderly patients, and set a new gold standard for medicines optimisation? The answer isn’t just in the data. It’s in the story behind the numbers.

Key Takeaways:

• Dedicated pharmacist support is crucial for achieving complex NHS targets and improving patient outcomes in primary care.

• Standardised protocols and centralised oversight ensure consistent, high-quality care across multiple GP practices.

• Comprehensive medication reviews for elderly patients significantly reduce polypharmacy risks and enhance medication safety.

• Data-driven patient identification and evidence-based interventions maximise clinical impact and resource efficiency.

• Collaborative partnerships between pharmacists and practice teams protect staff wellbeing and drive sustainable practice success.

The Challenge: Complex Targets in Primary Care

Vale of Evesham Primary Care Network (PCN) serves a diverse population of over 62,500 patients across seven GP practices in Herefordshire and Worcestershire. Like many PCNs, they faced mounting pressure to deliver on ambitious NHS targets, specifically, the Contract and Enhanced Investment Framework (CEIF) and Cardiovascular Disease Quality and Outcomes Framework (CVD QOF).

Key Obstacles

• Resource Constraints: Existing GP and nursing staff were already stretched thin, making it nearly impossible to take on additional systematic patient reviews.

• Multi-Practice Coordination: Each of the seven practices operated with unique workflows, complicating the delivery of consistent, high-quality care.

• Complex Clinical Demands: The PCN needed to address multiple, overlapping clinical priorities, including:

  • Meeting all CEIF requirements to secure essential practice income.

  • Achieving comprehensive CVD management for optimal patient outcomes.

  • Addressing polypharmacy and medication safety, especially for patients aged 85+.

  • Implementing evidence-based interventions for cholesterol, hypertension, and medication optimisation.

Without dedicated pharmacist support, the risk of missed targets, suboptimal patient care, and financial shortfalls was high.

The Solution: The Medicines Management Team’s Specialist Approach

Recognising the scale and complexity of the challenge, Vale of Evesham PCN partnered with The Medicines Management Team to deliver a comprehensive, pharmacist-led solution.

How TMMT Made the Difference

1. Deployment of Specialist Pharmacists

TMMT provided experienced pharmacists with expertise in cardiovascular disease, medication optimisation, and elderly care. These professionals were embedded across all seven practices, ensuring every site benefited from consistent, high-quality interventions.

2. Standardised, Scalable Protocols

• Centralised Quality Oversight: TMMT implemented standardised clinical protocols and coordinated scheduling, ensuring every practice followed best practice guidelines.

• Integrated Workflows: Pharmacists worked closely with existing teams, accessing patient records and integrating interventions into routine care.

3. Data-Driven Patient Identification

Using EMIS clinical system searches, TMMT systematically identified patients who would benefit most from interventions, prioritising those at highest risk or with multiple needs.

4. Evidence-Based Clinical Interventions

All interventions were guided by the latest NICE guidelines and local formularies, ensuring every clinical decision was defensible and up-to-date.

Implementation:

Structured Medication Reviews (SMRs) for the Elderly

One of the most impactful elements was the completion of over 1,000 comprehensive SMRs for patients aged 85 and above. These reviews included:

• Detailed medication history analysis

• Drug interaction checks

• Deprescribing where appropriate

• Patient and carer consultations

This approach significantly reduced polypharmacy risks and improved medication safety for the most vulnerable patients.

Cardiovascular Risk Management

TMMT ensured 100% of patients with a QRISK score above 20% were identified and managed. This included:

• Cardiovascular risk assessments

• Lifestyle intervention advice

• Optimisation of preventative medication therapy

Diabetes-Related CVD Prevention

For over 250 diabetic patients, TMMT:

• Reviewed and optimised statin therapy

• Supported cholesterol monitoring and medication reconciliation

• Provided adherence support and ensured relevant diagnoses were up to date

Cholesterol and Hypertension Management

• Cholesterol (CHOL003): Systematic identification and treatment of patients with primary hypercholesterolaemia.

• Hypertension QOF: Achieved 100% of hypertension targets through regular blood pressure monitoring, medication reviews, and treatment intensification where needed.

Medication Safety Initiatives

• Melatonin Optimisation: Reviewed therapy for 300+ patients, ensuring sleep medications were used appropriately.

• Iron Supplement Review: Assessed 300+ patients to reduce unnecessary continuation and minimise adverse effects.

Results

By the Numbers

• 2,050+ clinical interventions delivered

• 1,000+ SMRs for elderly patients

• 100% achievement of all CEIF and CVD QOF targets

• 250+ statin therapy reviews for diabetic patients

• 300+ melatonin and iron supplement reviews each

Key Benefits

1. Perfect Target Achievement

Every single CEIF and CVD QOF target was met, securing maximum available income for the PCN and demonstrating excellence in quality improvement.

2. Enhanced Patient Safety and Care

• Elderly patients now benefit from safer, more appropriate prescribing.

• Patients with high cardiovascular risk are receiving optimal preventative treatment.

• Hundreds of patients have had unnecessary or potentially harmful medications reviewed and adjusted.

3. Practice Sustainability and Staff Wellbeing

By handling the intensive, target-driven workload, TMMT enabled GPs and nurses to focus on routine clinical care, reducing burnout and improving overall service delivery.

4. Consistent, High-Quality Service Across All Practices

Standardised protocols and centralised oversight ensured that every patient, regardless of which practice they attended, received the same high standard of care.

Lessons Learned: Best Practices for PCNs

What Made This Project a Success?

1. Dedicated Pharmacist Support: Specialist expertise is essential for meeting complex clinical and contractual targets.

2. Standardisation: Consistent protocols and centralised oversight drive quality and efficiency.

3. Collaboration: Close integration with existing practice teams ensures smooth implementation and sustainability.

4. Data-Driven Decision Making: Systematic patient identification maximises impact and resource allocation.

How Can Other PCNs Replicate This Success?

• Invest in dedicated pharmacist resources.

• Develop standardised, scalable protocols for multi-practice delivery.

• Use data analytics to prioritise high-impact interventions.

• Foster a culture of collaboration between pharmacists and practice staff.

Conclusion

The partnership between The Medicines Management Team and Vale of Evesham PCN is proof that ambitious NHS targets are not only achievable but can be exceeded with the right approach. By combining specialist pharmacist expertise, standardised protocols, and a collaborative mindset, PCNs can deliver measurable improvements in patient safety, clinical quality, and financial sustainability.

If your PCN is facing similar challenges, or if you’re aiming to achieve more with your medicines optimisation and CVD management programmes, The Medicines Management Team is ready to help you turn ambition into achievement.

Contact us to learn how we can help.