Project Name: Buckinghamshire Healthcare - Medical Day Unit Model of Care for Lipid Lowering Population Health Programme

Project Summary:

Buckinghamshire Healthcare NHS Trust (BHT) (the “CW Partner”), in collaboration with the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (“BOB ICS”), identified barriers in system-wide adoption of population health lipid management approaches, including: in the identification of patients with raised LDL-C, appropriate medical management and  barriers to the primary care execution of activities historically delivered within the secondary care setting, e.g., delivery of injectable therapies or the execution of patient injection training for suitable medicines, and the ability to deliver these at scale and pace. The result of this activity imbalance has resulted in the contribution of treatment and review backlogs at the CW Partner.

The CW partner has sought to alleviate challenges in patient identification and workforce capacity to expedite patient management and ASCVD risk reduction by the development of a new ASCVD lipids strategy.

This project aims to embed a new approach to lipid management by the implementation and utilisation of a population health search tool to facilitate identification, cohorting, and subsequent implementation of patient review and patient management via a Medical Day Unit Model of Care with the continued care of these patients being transferred to Primary Care.

Project Aims:

  • Demonstrate the impact of the utilisation of the Population Health Search tool technology solution (Graphnet) to enable secondary care organisations to identify, triage and manage patients with primary care records.
  • Establish and evaluate a novel approach to patient review to reduce the burden on secondary care clinicians, utilising a previously defined BHT ASCVD Protocol Proforma.
  • Reduce the backlog of referrals into secondary care.
  • Establish a Medical Day Unit model for the adoption of therapy initiations historically delivered by the secondary care lipid service.
  • Demonstrate a new model of integrated care within the Integrated Care system to improve speed and efficiency of patient treatment via a population health approach.
  • Ensure sustainability and care closer to patient homes by transition of review, initiation and continuation of care to primary care

In order to achieve this the Project aims to:

  • Increase capability of the lipid service to identify and stratify the patients with ASCVD via the commissioning and utilisation of a population healthcare tool for optimising CVD prevention. This tool will enable the identification and stratification of Buckinghamshire patients based on previous ASCVD conditions, medication use, blood tests (including LDL-C and total cholesterol) and deprivation scoring. This will be based upon the shared care record.
  • Identify ASCVD patients with sub-optimal treatment, who are not achieving a target LDL-C as per local guidance. 
  • Embed a sustainable model of patient review to support increased efficiency and capacity in ASCVD reviews via individual and personalised patient interactions; offering counselling on potential treatment options, lifestyle advice and adjustments. Long term continuity of this review model will be achieved by the addition of additional capacity to support referrals from primary care. 
  • Develop and evaluate a model to enable administration of subcutaneous therapies in both outpatient and community settings. Potential treatments for post- event ASCVD patients with an elevated LDL-C within the BOB ICS lipid guideline includes subcutaneous therapies. This project will develop a safe and effective model for the administration or delivery of injection training required, as per license based, upon treatment utilised (as appropriate) for these therapies.
  • Develop a comprehensive training program to help primary care providers deliver lipid therapy reviews, optimisation, and all NICE-approved lipid-lowering treatments, including injectables. They will work with providers individually to determine the best approach for each case and support development of medical management plans beyond the duration of the project.

This project has been extended and expanded as a significant number of new patients were identified as a result of the search tool (Graphnet) and changes in lipid testing profiles that more precisely identify patients at risk. It was also recognised during the project that comprehensive guidance and support is required to transition and sustain the continued care of patients by increasing capability within primary care. 

Planned Milestones:

  1. Graphnet Search Tool contract signed 
  2. Confirmation of recruitment of additional roles as defined in the contribution section 
  3. Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity (CW Partner shall ensure that the clinical staff covered by the Novartis Financial Contribution are appointed, trained and ready to begin clinical activity). Graphnet configuration complete and completion of initial cohorting processes 
  4. Collection of baseline data, in line with the Project Outcome Measures. Complete Graphnet Clinical Audit of population (Cohorting) and initiation of clinical activity
  5. Collection & submission of 3 months clinical activity data. Project Review meeting to discuss project progress
  6. Collection & submission of 6 months clinical activity data. Project Review meeting to discuss project progress
  7. Collection of data pertaining to incident ASCVD population identified via Primary Care. CW Partner and Novartis to conduct a joint review of any further requirement for additional virtual medical appointments and accessibility to medical day unit
  8. Collection & submission of 9 months clinical activity data. Project Review meeting to discuss project progress
  9. Collection & submission of 12 months clinical activity data. Project Review meeting to discuss project progress
  10. Confirmation of recruitment readiness and continuation of clinical activity
  11. Submission of transition to primary care project plan.  Project Review meeting to discuss project progress
  12. Collection & submission of 15 months clinical activity data. Written confirmation that the clinical staff covered by the Novartis Financial Contribution are delivering the next phase of clinical activity.  Evidence of Graphnet extension.  Submission of interim project report. Project Review meeting to discuss project progress
  13. Collection & submission of 18 months clinical activity data.  Transition to primary care 3 months activity data.  Project Review meeting to discuss project progress.
  14. Collection & submission of 21 months clinical activity data.  Transition to primary care 6 months activity data.  Project Review meeting to discuss project progress
  15. Collection & submission of 24 months clinical activity data.  Transition to primary care 9 months activity data.  Project Review meeting to discuss project progress
  16. Collection & submission of 27 months clinical activity data.  Transition to primary care 9 months activity data.  Project Review meeting to discuss project progress
  17. Anonymised report of location of treatment provision for patients previously managed in secondary care and review of options paper requirement. Submission of final project report and Outcomes Summary.  End of project review meeting

Expected Benefits:

Anticipated benefits for patients:

  • Faster access to all lipid lowering therapies in line NICE recommended therapies across the locality.
  • Reduced requirement for face-to-face medical engagement.
  • Reduction in requirement for primary care involvement.
  • Optimisation of a patient’s LDL-C is associated with a significant reduction in future cardiovascular events and may be associated reduction in morbidity/mortality. 
  • Reduction in the impact of health inequality in patient access to ASCVD treatment  
  • Care provided closer to patients’ homes
  • Increased awareness of lipid pathways in primary care, leading to improved access to both lipid and cardiovascular preventative NICE-approved medications in primary care

Anticipated benefits for partner organisation:

  • Development of a cardiovascular population health tool will support future approaches in long term conditions management thus reducing health inequalities and reducing emergency attendances. 
  • Demonstrate the impact of system wide visibility of patient characteristics.
  • Improvement to lipid lowering pathways with reform of pathway management streamlining the role of lipid specialists. 
  • Demonstration of the benefits of population healthcare for the Buckinghamshire population, supporting further population healthcare work in other specialties. 
  • Increase national awareness of Buckinghamshire’s work in population healthcare and preventative health.
  • Demonstration of a model of care to provide a mechanism for administration of injectable therapies 
  • Demonstration of the benefits of place-based working, including increased collaboration with primary care.

Anticipated Benefits for Novartis:

  • Demonstration of benefits of population health searches in detection of patients who could benefit from NICE approved therapies. 
  • Demonstration of collaborative working across a place-based system to rollout novel therapies. 
  • This project will support Novartis’ reputation and vision to make an impact in patients’ life by enhancing productivity and efficiency within the NHS.
  • Ethical, professional, and transparent relationship between Novartis and the NHS.
  • Better understanding of overall customers’ and patients’ needs
  • Optimal use of NICE approved medicines (including Novartis medicines) in appropriate patients

Start Date & Duration: September 2023 for 33 months. 

FA-11334278 | December 2024

Project Name: Buckinghamshire Healthcare - Medical Day Unit Model of Care for Lipid Lowering Population Health Programme

Organisation(s): Buckinghamshire Healthcare NHS Trust, Mandeville Rd, Aylesbury HP21 8AL

Completion Date: May 2026

Outcome Summary: 

This programme has successfully demonstrated the benefits of secondary care using a bespoke population health tool to identify and treat patients who are currently not reaching NICE targets for secondary prevention. 

The approach is scalable and has supported patients to receive a full range of NICE approved therapies at an ICB level.

Key Project Outcomes Data: 

  • Over 4,000 patients reviewed in virtual medical appointments, with those from areas of increased deprivation (Opportunity Bucks wards) prioritised in the first months of the programme. 
  • Over 5,500 virtual medical appointments provided, with over 67% of patients being recommended an up-titration of NICE approved cholesterol therapies. 
  • 1,407 eligible patients were referred for injectable lipid lowering therapies (based on Thames Valley Integrated Care System Guideline1 / NICE guidance2), with over 76% of them commencing injectable therapy. 
  • Education and training provided to 47 primary care teams in Buckinghamshire, with over 99.5% of patients receiving injectable therapies within the programme now able to receive them in their local GP practice.

Outcomes:

The Buckinghamshire Lipid Optimisation Programme used an innovative population health tool to identify eligible patients from the shared care record, integrating data from GP practices, acute hospitals, and social care. Secondary care clinicians identified patients across Buckinghamshire, based on their cardiovascular history, cholesterol levels, medications and prescribing patterns. Patients were proactively contacted and reviewed through virtual telephone consultations delivered by trained clinicians using a simplified protocol based on local and NICE guidance.

Over 2.5 years, more than 4,000 patients received cholesterol management reviews, delivered at a pace approximately 14 times faster than traditional secondary care pathways. The programme prioritised patients at greatest risk of health inequalities, with initial reviews focused on the most deprived communities in Buckinghamshire. Evening and weekend clinics improved accessibility and demonstrated the value of a flexible locum workforce.

The programme enabled eligible patients to access all NICE approved lipid lowering therapies, including injectable medications delivered through senior nurse led clinics. 

More than 67% of patients were offered optimisation of lipid lowering therapy, including 1,407 high-risk patients referred for injectable lipid lowering therapies. Medication administration clinics operated at significant scale and efficiency, with some clinics treating over 100 patients in a single day. 

After 12 months, in those with up to date blood tests, 33.8% of those attending a virtual medical appointment had achieved their LDL-C targets, often after years of uncontrolled cholesterol levels. 59% of patients achieved LDL-C targets in those in the cohort receiving injectable therapies. Patient satisfaction was high, with over 98% of patients stating they would recommend the service.

Strong executive sponsorship from the Chief Executive and Chief Medical Officer positioned the programme as a strategic priority. Consistent communication and regional education events resulted in a shared endeavor across the ICB. The programme strengthened primary care capability through specialist education and support delivered to every GP practice in Buckinghamshire. As a result, over 97% will be prescribing and administering injectable cholesterol treatments locally. This has embedded sustainable cardiovascular prevention within neighbourhood teams and reduced reliance on secondary care services.

Additional clinical benefits were realised through the programme. More than 40 patients with suspected familial hypercholesterolaemia were identified and referred for specialist assessment. Simplified pathology requesting increased identification of at-risk patients by 138%, by increasing the number of LDL-C tests performed. Over 100 patients were also identified and switched from potentially unsafe medication dosages based on information within the shared care record.

A health economic model developed with Health Innovation Oxford has projected savings of more than £830,000 in direct NHS costs within three years, alongside the prevention of over 81 cardiovascular events.

The model has gained national recognition, and funding has subsequently been secured from the British Heart Foundation to fund a similar population health programme for a further 4,000 patients in Buckinghamshire. The Thames Valley Acute Provider Collaborative is exploring expansion of the programme across the Integrated Care Board, seeking to expand the benefits of the Buckinghamshire programme for patients across Thames Valley.

Conclusion: 

Buckinghamshire Healthcare NHS Trust continues to use its innovative population health approach to tackle causes of cardiovascular diseases. It has recently been awarded grant funding from the British Heart Foundation to utilise this approach in a different patient cohort.

Separately, the Trust is working with the Thames Valley Acute Provider Collaborative and ICB on a proposal to expand this work across the entire Thames Valley region. This would benefit over 12,000 patients.

References: 

  1. Thames Valley Integrated Care System Guideline BOB Lipid Modification Guideline [Last accessed October 2026]
  2. NICE Guidance Lipid modification - CVD prevention | Health topics A to Z | CKS | NICE [Last accessed October 2026]

October 2026 | FA-11818981