Project Name: Bristol Heart Institute Nurse Led ASCV and Lipid Prevention Model of Care

Project Summary:

The main objective of the CWP is to improve the quality of care for patients and support the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner.   

This project aims to implement a local secondary care led secondary prevention clinic, focusing on supporting the discharge and onward management of secondary prevention patients, including first dose medicine optimisation, and subsequent transfer to primary care setting.

The CWP will be co-led by a Nurse band 7 and a Nurse band 6 alongside a multi-disciplinary team; including a consultant cardiologist (x2) and a Band 7 Management/Administrative Support, aiming to achieve:

  • Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines.
  • Identification of ASCVD patients who have previously not tolerated or refused alternative lipid modification therapies.
  • Review of treatment options and decision on next steps in collaboration with ASCVD patients.
  • Counsel and optimise ASCVD patients where appropriate.
  • Early identification of at-risk patients who have not had intervention in their health and wellbeing.
  • Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated.
  • On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably.

Expected Benefits:

Anticipated benefits for patients:

  • Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.  
  • Enhanced experience around ASCVD with ongoing management of the condition.  
  • Improved access to appropriate medication for suitable patients to preserve health and prevent long-term events 
  • Easier access to lipid management care closer to home in the Primary Care setting.

Anticipated benefits for organisation(s):

  • Increased proportion of ASCVD patients reviewed by primary care   
  • Increased proportion of ASCVD patients receiving expert and timely review closer to home  
  • Reduction in ASCVD referral rates to secondary care  
  • Increased proportion of patients receiving guideline-directed pharmacotherapy  
  • Insight into benefits of primary care pharmacist led lipid management clinics in primary care   
  • Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES 

Anticipated benefits for Novartis: 

  • Insight on the appropriate use of ASCVD licensed medicines in line with NICE guidelines, including Novartis’s medicine  
  • Enhanced reputation, and supporting Novartis’ vision that no patient should have to wait for an extraordinary life, by supporting high quality Collaborative Working with healthcare organisations which addresses the problem of health inequalities    
  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation  

Start Date & Duration: 01/02/2023. 21 months. 

FA-11429909 | June 2025

Project Name: Bristol Heart Institute Nurse Led ASCV and Lipid Prevention Model of Care

Organisation(s): Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU 

Completion Date: June 2025

Outcome Summary: 

Our collaboration successfully implemented a nurse-led strategy to optimise lipid management and review patients within the cardiac rehabilitation footprint. We achieved the objective to improve lipid management in high-risk patients and increase patient engagement with cardiac rehabilitation. 

Key Project Outcomes Data: 

Reduced waiting time to clinic from 37 to 10-14 weeks.

On admission to hospital, only 10.5% of patients met lipid targets; at the first clinic visit, this improved to 36.8%, and by the six-month visit, 54.4% met the target.

Outcomes: 

  • Reduced waiting time to clinic from 37 to 10-14 weeks
  • On admission to hospital, only 10.5% of patients met lipid targets; at the first clinic visit, this improved to 36.8%, and by the six-month visit, 54.4% met the target.
  • Increased engagement from patients with the cardiac rehabilitation program, offering individualised risk factor optimisation
  • Positive feedback from patients through qualitative feedback questionnaires, with 100% agreement on this being a useful addition to the cardiac rehabilitation service.
  • Increased engagement from healthcare professionals in both primary and secondary care, with multiple education sessions led, reaching over 500 people

Conclusion: 

This project has successfully demonstrated the value of a structured, collaborative approach to lipid management within cardiac rehab. By identifying at-risk patients, facilitating timely reviews, and supporting the appropriate use of lipid-lowering therapies, it delivered measurable clinical outcomes and supported national CVD prevention goals.

The involvement of pharmacy teams and the integration of innovative therapies highlighted the potential for wider multidisciplinary working and more efficient use of resources. In addition, the partnership model between the PCN, practices and Novartis showcased how industry collaboration can support service delivery without compromising clinical independence.

To ensure sustainability of the project outcomes the CW Partner aims to:

  • Explore further integration of digital tools and decision support to streamline future reviews.
  • Continue capacity building within pharmacy and clinical teams to sustain lipid optimisation as part of routine care.

Evaluate longer-term outcomes, including lipid profiles and cardiovascular events, to assess the ongoing impact of interventions

FA-11576691 | December 2025