Strategy
The service was sequentially rolled out and evaluated over four Plan–Do–Study–Act (PDSA) audit cycles.

PDSA Cycle 1 (1 September 2013–31 August 2014)
PLAN: Clinics were piloted in two hospitals: Royal Alexandra Hospital and Vale of Leven. This pilot concentrated on patients with moderate or severe LVSD and was supported by funding from NHS Education for Scotland.
DO: Two pharmacists (NHS Agenda for Change (AFC) Band 8a) with between 5 and 9 years of cardiology experience, who were already qualified independent prescribers and trained in clinical examination and venepuncture, delivered the clinics in an outpatient setting.

PDSA Cycle 2 (1 September 2014–31 August 2015)
PLAN: Clinics were rolled out to two further hospitals: West Glasgow Ambulatory Care Hospital and Glasgow Royal Infirmary. Retrospective baseline data were collected from Glasgow Royal Infirmary for the 6 months preceding initiation of the clinic to ensure that there was a similar requirement for the clinic. No baseline data were collected in West Glasgow Ambulatory Care Hospital, as the original site of this hospital closed during this period making consecutive patient data collection impossible. To support the roll-out and criteria widening (to all grades of LVSD), the model was developed into ‘hub’ and ‘spoke’ clinics. Pharmacist independent prescribers with different levels of cardiology experience were recruited to deliver stratified clinics depending on the risk profile of the patient. The risk profile was assessed by the experienced PDSA Cycle 1 pharmacists at the point of vetting. In each hospital site, specialist cardiology pharmacists were used to deliver a ‘hub’ clinic for patients with moderate or severe grades of LVSD, or those with additional risk factors (eg, signs and symptoms of ischaemia, significant residual coronary heart disease or complex comorbidities). In surrounding primary care localities, such as local health centres, General Practice (GP)-based pharmacists were used to deliver ‘spoke’ clinics for patients with mild LVSD. GP-based pharmacists were general clinicians and were peer supported remotely by specialist cardiology pharmacists. This phase of the project was supported by funding from NHS Education for Scotland.
DO: Two additional specialist pharmacists were used, both already experienced prescribers with 9–25 years of cardiology experience (AFC Bands 8a and 8b). An additional nine generalist GP-based pharmacists (AFC Band 8a) were trained to deliver primary care clinics through a bespoke local education and training programme—‘Teach and Treat’. This programme included experiential learning, taught lectures, online webinars, links to national guidelines, physical examination training (including blood pressure/pulse measurement, pitting for oedema and chest auscultation) and venepuncture. At the end of the training, all pharmacists sat a multiple-choice examination and an objective structured clinical examination, developed in partnership between the experienced PDSA Cycle 1 pharmacists and a consultant cardiologist, to assess competence before commencing autonomous clinic work.

PDSA Cycle 3 (1 September 2015–31 August 2016)
PLAN: Clinics were rolled out to two further hospital sites: New Victoria Infirmary and Queen Elizabeth University Hospital. As before, retrospective baseline data were collected from both sites for the preceding 12 months. The Queen Elizabeth University Hospital opened during this time period but baseline data were able to be characterised from its predecessor, the Southern General Hospital. Unlike the other sites, the Southern General Hospital provided a consultant cardiologist-led post-MI clinic approximately 1 month postdischarge at baseline.
DO: An additional specialist pharmacist IP (AFC Band 7), with 14 years of cardiology experience, was trained and deployed in one of the ‘hub’ clinics. The other new specialist ‘hub’ clinic was delivered by an existing service pharmacist. An additional two generalist GP-based pharmacists (AFC Band 8a) were trained to deliver primary care clinics. All were independent prescribers.

PDSA Cycle 4 (1 September 2016–31 August 2017)
PLAN: Clinics were rolled out to the final hospital site: Inverclyde Royal Hospital. Baseline data were not available from Inverclyde Royal Hospital due to a lack of a baseline cardiac rehabilitation database.
DO: Two additional specialist pharmacists (AFC Bands 7 and 8b), with 6 and 19 years of cardiology experience, respectively, and two additional generalist GP-based pharmacist (AFC Band 8a) were recruited to deliver ‘hub’ and ‘spoke’ clinics, respectively. All pharmacists were trained as described above and were independent prescribers.