Project Name: Gateshead Secondary Prevention ASCVD MDT Clinic
Project Summary:
The CWP is structured such that a Band 8A Clinical Pharmacist and Health Care Assistant (HCA) are supported by a multi-disciplinary health professional team, will provide tailored care for patients aiming towards early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD), previous cerebrovascular accident (CVA or TIA) and/or peripheral vascular disease (PVD) for 12 months clinical activity out of an 18 months project.
All patients referred into the service will be discussed at a consultant-led MDT, with appropriate patients receiving specialist clinic review thereafter. Currently there is a 12-week waiting list time with and additional 4-6 week wait for implementation of lipid optimisation.
There is also the opportunity for the Band 8A clinical pharmacist to liaise with the PCN pharmacists in the area to create a “lipid-optimisation network” aiming to offer advice and support for lipid-related queries, supported by the MDT.
Aims are:
- Identification of patients with ASCVD/PVD/CVA who are not achieving secondary prevention lipid targets as specified in national guidelines
- Identification of ASCVD/PVD/CVA patients who have previously not tolerated lipid modification therapies and therefore have not reached secondary prevention lipid targets
- Review and medicines optimisation for ASCVD/PVD/CVA patients who have associated cardiovascular risk factors including diabetes and hypertension
- Review of treatment options and decisions on next steps in collaboration with patients
- Medicines optimisation post-MI including titration of secondary prevention medication (e.g., beta-blockers, ACE-inhibitors), including heart failure medication where applicable
- Counsel and support patients with regards to starting and continuing secondary prevention medication
- Onward referral of patients to specialist lipid clinic who meet criteria for assessment of familial hypercholesterolaemia or other inherited lipid disorders; or to diabetes clinic for specialist input where needed
Planned Milestones:
- Kick off meeting and Collection of baseline data
- Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity
- Confirmation of recruitment of Band 8A clinical pharmacist
- The clinical staff are trained and ready to begin clinical activity.
- Collection & submission of 3 months clinical activity data.
- Collection & submission of 6 months clinical activity data.
- Collection & submission of 9 months clinical activity data.
- Collection & submission of 12 months clinical activity data.
- Development of business case and submission to the Trust board
- Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary
Expected Benefits:
ANTICIPATED BENEFITS FOR PATIENTS
- Improved access to specialist lipid management, diabetes and cardiology care leading to optimal secondary prevention of future ASCVD/CVA/PVD
- Improved access to appropriate NICE-approved medication for suitable patients to preserve health and prevent long-term events
- Access to specialist secondary prevention services based in local hospital
ANTICIPATED BENEFITS FOR THE ORGANISATION(S)
- Increased proportion of ASCVD/CVA/PVD patients being referred to and receiving care in dedicated specialist secondary prevention MDT and clinic.
- Increased proportion of patients receiving guideline-directed pharmacotherapy
- Provide patient tailored support and education to promote adherence with treatment and optimisation of non-HDL levels and other risk factors for ASCVD/CVA/PVD (diabetes, hypertension etc)
- Align and collaborate with regional services i.e., Newcastle ASCVD Service to optimise patient management
- Reduce health inequalities within Gateshead as patients will have a local specialist secondary prevention service to access and will not need to travel out of area for this
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: June 2023 for 18 months
UK2306050148
Project Name: Gateshead Secondary Prevention ASCVD MDT Clinic
Partner Organisation(s): Gateshead Health NHS Foundation Trust. Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead, NE9 6SX (the “CW Partner”)
Completion Date: 29.04.2025
Outcome Summary:
The development of a multidisciplinary team (MDT) approach for secondary prevention of ASCVD represents an improvement in addressing the high residual risk faced by this patient population in Gateshead. Collaboration across specialties enables more coordinated, personalised care and ensures that the full spectrum of cardiovascular risk factors is addressed.
Key Project Outcomes Data:
| Outcome Measure | Baseline Cohort | Total patients reviewed during 12-month period |
|---|---|---|
| Number of patients with ASCVD and sub optimally managed cardiovascular risk factors being identified | 284 patients in 3 months (Jan-Mar 2022) eligible 213/284 not optimised (75%) | 575 patients in 12 months 430/575 not optimised (74.9%) |
| Number of patients with the above characteristics accepting input from the service | n/a | 575 patients accepting of input |
% of patients having optimized lipid profile (non-HDL cholesterol<2.5mmol/L) | 90/284 suboptimal lipids (32%) | 289/575 with suboptimal lipids (50.2%) |
% of patients having optimized HbA1c (<53mmol/mmol) | 43/284 suboptimal diabetes control (15.1%) | 93/158 suboptimal diabetes control (58.7%) |
| % of patients having optimized post-MI medication (ACEi/ARB, Beta-blocker, antiplatelets) | 8/284 could have adjusted post-MI medication (2.8%) | 108/224 could have adjusted post-MI medication (48.2%) |
% of patients having optimized heart failure (SGLT-2i, eplerenone) | 6/6 patients optimised (100%) | 15/22 patients optimised (68.2%) |
| Number of patients referred from Newcastle ASCVD Service | N/A as patients from Gateshead were not repatriated back before the CW started | 36 patients |
| Identification of ongoing sustainable resource requirement for maintenance long term secondary prevention pathway | n/a | Successful business case approval for substantive lipid optimisation and secondary prevention pharmacist post |
| Patient and Clinician Satisfaction questionnaires | n/a | 101 Questionnaires returned rating the service on average 4.7/5 |
Conclusion:
The development of a multidisciplinary team (MDT) approach for secondary prevention of ASCVD represents an improvement in addressing the high residual risk faced by this patient population in Gateshead. Collaboration across specialties enables more coordinated, personalised care and ensures that the full spectrum of cardiovascular risk factors is addressed. However, despite the availability of NICE-approved therapies, many patients remain sub-optimally treated.
To bridge this gap, the team at Gateshead believe the MDT must continue to evolve, focusing on strengthening inter-specialty collaboration, enhancing education in primary care, and embedding robust, patient-centred pathways across both inpatient and outpatient settings. In doing so, we can align with the NHS Long-Term ambition to shift “from treatment to prevention”, reducing future cardiovascular events and improving long-term outcomes for affected patients. A well-established ASCVD MDT not only supports clinical excellence but also drives health system efficiency by ensuring that every opportunity for intervention is maximised.
Additional Content:
Poster presentation – HEART UK 37th Annual Medical and Scientific Conference, 10-12 July 2024 (Coventry, UK)
Winner – Outstanding NHS Industry Collaboration, Bright Ideas in Health Awards, November 2024
Poster presentation – American College of Cardiology (ACC) Conference, 29-31 March 2025 (Chicago, USA)
Poster presentation – European Atherosclerosis Society (EAS) 93rd Congress, 4-7 May 2025 (Glasgow, UK)
FA-11445918 | June 2025