Project Name: Aegis PCN 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 optimisation of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of Aegis Healthcare PCN. Willows Health is the Lead Practice for Aegis Healthcare PCN. Novartis will contract with Willows Health as they are the legal entity contracting on behalf of Aegis Healthcare PCN. 

The CWP 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:

Aegis PCN Table

Expected Benefits: 

Anticipated Benefits to 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, leveling health inequalities within the PCN.

Anticipated Benefits to the 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 Benefit to 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: February 2023 for 15 Months