Project Name: Fieldhead Surgery ASCVD Primary Care Lipid Management Collaborative Working Project

Project Summary:

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

Planned Milestones:

  • Project kick-off meeting
  • Pathway and protocol development
  • Baseline data
  • Clinical Audit and Clinical Audit Discussion with Member Practices
  • Collection & submission of 3 months clinical activity data at months 3, 6, 9 and 12
  • Business case for future funding
  • Analysis of CWP data, submission of Final CWP Report, Submission of Outcomes Summary
  • Project close out meeting

Expected Benefits:


  • 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 CWP HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, leveling health inequalities within the four surgeries.  

CW Partner:

  • 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


  • 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: March 2023 for 15 months