Supporting primary care networks to develop new care pathways for people at risk of CVD

Innovation and training in primary care redesign

Approximately 15 million people in England are living with long term conditions (LTCs) and have the greatest healthcare needs of the population (50% of all GP appointments and 70% of all bed days). It is estimated that treatment and care of this cohort absorbs 70% of acute and primary care budgets in England.

The NHS Long Term Plan made a commitment to provide extra support for prevention and management of disease, however, further work is required to develop data driven solutions to identify the patients that would benefit from early intervention.

The opportunity

The National CLEAR Programme with NHS England is offering support to two PCNs to:

• identify patients from PCN data who are at risk of developing CVD and other related long-term conditions in line with the Network Contract DES

• design innovative new models of care and workforce to proactively care for this population cohort.

Prospective organisations will submit expressions of interest to CLEAR and NHSE.

More detail on the type of support is detailed below. If you have any questions about the offer, please contact

What will it involve?

We are inviting PCNs in England to submit an expression of interest (EOI) to take part in the CLEAR Living Well programme.
This is a competitive process with places limited to two PCNs in England.

The projects are performed concurrently to ensure shared learning and education between projects and across systems. This means that the timelines for network preparation and on-the-ground delivery are fixed to ensure the successful choreography of all project sites together.

A successful expression of interest will require the full commitment and input from:
• Executive sponsor for the project
• Clinical lead for the project
• Network team leads for information governance (IG) and data.

The requirements for each role are outlined fully within the EOI document. A successful EOI will need the representatives listed above to have completed relevant agreements, which are found within the EOI.

Find out more about Living Well from our webinar below:

Dates  Action required for prospective CLEAR Living Well project sites
1 July 2022 Expression of interest application opens, and a series of webinars are offered to provide information and an opportunity for questions.
13 & 21 July Webinars (please email to confirm your place).
30 July EOI closes (deadline for submission).
W/c 9 August Interviews with PCNs to confirm the final two sites.
W/c 15 August Sites informed of the interview outcome and project launch of shortlisted networks, the PCNs have approximately four months to complete data sharing agreements, facilitate data extraction, recruit participants and prepare for on-the-ground delivery.
W/c 22 August Provide dates for a planning and engagement meeting for your team.
January 2023 Successful networks which have completed milestones will commence the education, training and project delivery.
July 2023 Completion of projects and consideration of findings.

Submitting an expression of interest (EOI)

If you or your PCN are interested in project support to support patients with LTCs and CVD, please read and complete all sections of the complete EOI document.

EOIs will need to be submitted by Saturday 30 July 2022 by email to

What CLEAR offers