Project Name: SE London Lipid pathway transformation project #guardyourheart
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 Guy’s and HIN
- The CWP will be led by the senior lipid clinical team across Health Innovation Network South East London and Guys with addition of 3 Senior Specialist Pharmacists ( and a clinic coordinator alongside the existing multi-disciplinary team, aiming to achieve:
- Increase in number of patients with ASCVD and uncontrolled lipid levels being identified compared to baseline.
- Number of patients with ASCVD and uncontrolled lipid levels accessing the service. Prioritising High-risk ASCVD patients with uncontrolled lipid levels defined by the local or national protocol, prioritising cohorts 1 and 4 as defined by using the UCLP measures.
- Number of patients with ASCVD achieving target set out in local or national protocols
- Improve speed of patient access - achieve reduction in the amount of time taken between patient identification and the patient being seen in clinic from baseline
- Number of educational sessions delivered with the wider HCP’s in the community.
- Reduction in the overall backlog of existing patients with ASCVD waiting to be seen by a pharmacist for follow up, review, and medicines optimisation from baseline (start date of clinical activity).
- Increase in the number of patients being able to access all NICE approved medicines for the treatment of ASCVD.
- Identification of ongoing sustainable resource requirement for maintenance long term lipid management pathway
- Collect patient reported experience measures linked to the introduction of CWP
Planned Milestones:
- Kick off meeting
- Confirmation of appointment of personnel.
- Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table
- Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity;
- Confirmation of recruitment of Clinical pharmacist
- Collection & submission of 3 months clinical activity data.
- Project Review meeting to discuss project progress.
- Collection & submission of 6 months clinical activity data.
- Project Review meeting to discuss project progress.
- Collection & submission of 9 months clinical activity data.
- Project Review meeting to discuss project progress.
- Collection & submission of 12 months clinical activity data.
- Project Review meeting to discuss project progress.
- Development of business case and submission to the Trust and /or ICS
- Collection & submission of 15 months clinical activity data.
- Project Review meeting to discuss project progress.
- Collection & submission of 18 months clinical activity data.
- Project Review meeting to discuss project progress.
- post 18 months of recruitment of pharmacist
- Analysis of CWP data from all sites, 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
- Easier access to lipid management care closer to home in the Primary Care setting
- 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 the 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:
- 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: March 2023 for 24 months
UK2303209212
Project Name: SE London Lipid pathway transformation project
Partner Organisation(s): GUY’S AND ST THOMAS’ NHS FOUNDATION TRUST AND Health Innovation Network (South London)
Completion Date: 30th June 2025
Outcome Summary:
The South East London Lipid Pathway Transformation Programme was a successful collaborative working partnership between Guy's and St Thomas' NHS Foundation Trust, the Health Innovation Network, and Novartis. This programme embedded three highly specialist cardiovascular pharmacists across the South East London Integrated Care System to address substantial unmet needs in lipid and cardiovascular disease management.
Key Project Outcomes Data:
2,784 high-risk patients directly engaged through targeted interventions
1,427 comprehensive case reviews completed
1,378 healthcare professionals trained across 60 education sessions
85% of these attendees reported increased confidence in lipid management
Waiting time reductions:
Lewisham: 18 months → 6 months initially, then 11 months due to increased appropriate referrals (39% net reduction)
PRUH: 9 months → 6 months (33% reduction)
King's College Hospital: 6 months → 13 weeks (50% reduction)
St Thomas': 6 months → 13 weeks (50% reduction)
Outcomes:
Cardiovascular pharmacists with specialist expertise were integrated within local healthcare systems to enhance patient care. Efforts to remove traditional barriers between sectors supported greater cross-sector collaboration, while patient stratification ensured that high-need groups were prioritised for intervention. Workforce education initiatives focused on upskilling professionals to meet evolving care demands, and expanding access to NICE-approved lipid-lowering therapies across the entire care pathway further strengthened therapeutic utilisation and patient outcomes.
Conclusion:
This project demonstrated the significant impact that highly specialist cardiovascular pharmacists can have on addressing population health challenges. The programme achieved substantial clinical, economic, and system outcomes through innovative cross-sector working and targeted interventions.
This pharmacist-led model is scalable, with strong potential for adaptation across other healthcare settings and expansion to cardiorenal-metabolic disease areas, delivering measurable improvements in patient outcomes and system efficiency whilst addressing health inequalities.
The programme represents an effective model for cardiovascular disease prevention, delivering comprehensive improvements across clinical practice, system efficiency, and equity of care.
This project demonstrated that cross-sector collaboration is highly effective. The embedded pharmacist model, implemented across primary, secondary, and community care, proved highly successful, with 85% of clinicians reporting increased confidence. Breaking down traditional care boundaries was essential to programme success.
Comprehensive education created a lasting impact beyond the programme period, leading to improved referral quality and increased clinician confidence in lipid management across all therapeutic options.
FA-11539609 | October 2025