Project Name: ASCVD Primary Care Lipid Management Collaborative Working Project

Project Summary:

The project is structured such that a multi-disciplinary health professional team will provide tailored care for patients, aligned with the Primary Care Networks (PCNs) Contract Direct Enhanced Service) DES and the Locally defined Cardiovascular plans.  

The main objective of the project 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 Cross Counties PCN.

The project will be led by a Clinical Pharmacist alongside a multi-disciplinary team; including Pharmacy Technician, Healthcare Assistant, Administrative Support, General Practitioner providing clinical oversight aiming to achieve:

  1. Identification of sub-optimally treated patients who are not achieving recommended targets for lipid management  
  2. Identification of patients who have previously not tolerated or refused alternative lipid modification therapies  
  3. Review of treatment options and decision on next steps in collaboration with patients  
  4. Counsel and optimise patients where appropriate  
  5. Early identification of at-risk patients who have not had intervention in their health and wellbeing 
  6. Identification of patients, following risk assessment review, of patients who are sub-optimally treated  

Planned Milestones:

  1. Kick-off Meeting with project Leads
  2. PCN Level Lipid Management pathway/protocol development
  3. Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table
  4. Clinical Audit and Clinical Audit Discussion with Member Practices
  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 & submission of 9 months clinical activity data. Project Review meeting to discuss project progress
  8. Collection & submission of 12 months clinical activity data. Project Review meeting to discuss project progress
  9. Development of business case 
  10. Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary

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 
  • The additional capacity will provide additional time and support from PCN HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, levelling health inequalities within the PCN. 

Anticipated benefits for partner organisation:

  • 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 healthcare organisations 

Start Date & Duration: December 2022 for 15 months