Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone Kent, ME16 9QQ

Project Name: ASCVD community-based lipid optimisation with Maidstone and Tunbridge Wells Trust

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 Network (PCN) 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) who are at high risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance. In response to the needs of the CW Partner, Novartis will contract with Maidstone and Tunbridge Wells NHS Trust as the legal entity.

The CWP will be led by a Clinical Pharmacist band 8b alongside a multi-disciplinary team; including Maidstone and Tunbridge Wells (MTW)  Consultants and specialist teams in Metabolic Medicine,  Stroke Care and PCN Clinical Pharmacists and General Practitioners aiming to achieve:

1. Identification of sub-optimally treated ASCVD patients (secondary prevention) who are at high risk of another cardiovascular event and are not achieving lipid levels as specified in national and/or local guidelines
2. Identification of ASCVD patients who are at higher risk of cardiovascular events and who have previously not tolerated or refused alternative lipid modification therapies (secondary prevention)
3. Review of treatment options and decision on next steps in collaboration with ASCVD patients
4. Counsel and optimise ASCVD patients where appropriate including other modifiable risk factors, including health and wellbeing advice (non-pharmacological interventions)  
5. Early identification of secondary prevention ASCVD at-risk patients who have not had intervention in their health and wellbeing.
6. Identification of ASCVD patients, following risk assessment review, who are sub-optimally treated.
7. On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably 

The Trust will ensure review of high risk ASCVD patients (secondary prevention) as detailed above in the following PCNs

• ABC PCN
• Malling PCN
• Tunbridge Wells PCN

Planned Milestones:

Expected Benefits:

Anticipated patient 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  
• 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 a GP appointment or been lost to follow-up. 
• Provide specialist expertise to help address public health and social care needs of patients to tackle health inequalities.

Anticipated organistaion benefits;
• 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 a pharmacist led lipid management clinics in primary care   

Anticipated Novartis benefits;
• 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 Organisations

Start Date & Duration: November 2023 18 month project. This executive summary was amended May 2024.

UK2406065987

Project Name: ASCVD community-based lipid optimisation with Maidstone and Tunbridge Wells NHS Trust 

Partner Organisation(s): Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone Kent, ME16 9QQ   

Completion Date: 04/06/2025

Outcome Summary: 

The ASCVD Community-Based Lipid Optimisation Project was successfully implemented across three Primary Care Networks (PCNs) in Kent, targeting patients with established atherosclerotic cardiovascular disease (ASCVD) and suboptimal lipid control. Through pharmacist-led reviews and evidence-based prescribing interventions, over 250 medication optimisations were achieved, highlighting the critical role of specialist lipid management in primary care for reducing cardiovascular risk and improving long-term outcomes in patients with established ASCVD. 

Key Project Outcomes Data:

• Following the initial desktop review of over 1,000 patients, 608 patients received a comprehensive clinical review for lipid optimisation.
• 276 prescribing interventions were implemented in line with national guidelines.

Outcomes: 

The ASCVD Community-Based Lipid Optimisation Project successfully deployed a 1.0 WTE Advanced Pharmacist (delivered through two individuals), enabling systematic identification and clinical management of patients with established atherosclerotic cardiovascular disease (ASCVD) and persistently elevated low-density lipoprotein cholesterol (LDL-C). 

All contractual milestones were achieved on schedule, including a formal project kick-off meeting, development of clinical and operational pathways, policy and protocol creation, pharmacist recruitment, and 12 months of clinical activity across three Primary Care Networks (PCNs).

During the delivery phase, 276 interventions were implemented in line with national guidelines, including statin initiation, dose intensification, and adjunctive use of ezetimibe, bempedoic acid, or fibrates, referral to Lipid clinic for PCSK9i injections, or referral to patients’ GPs for siRNA initiation.

Additionally, over 250 non-pharmaceutical interventions were completed, which included ASCVD-specific lifestyle advice, patient signposting to relevant health services and behavioural counselling for smoking cessation and alcohol reduction.

From an NHS perspective, the project has demonstrated the feasibility and impact of integrating advanced clinical pharmacists into lipid management pathways within primary care. This approach supports delivery of the NHS Long Term Plan, which calls for proactive identification and early treatment of high-risk cardiovascular patients to reduce preventable morbidity and mortality. Given that cardiovascular disease causes over 25% of deaths in the UK and contributes significantly to NHS expenditure, this intervention also represents a potential reduction in long-term healthcare costs.

For patients, the project delivered improved access to lipid-lowering therapies from specialists, greater continuity of care, and personalised support. Those enrolled in the programme benefited from pharmacist-led reviews, timely treatment, and education to promote self-management—resulting in better engagement and outcomes.

For Novartis, this project reinforces the value of its population health management agreement with the NHS, aimed at addressing high cholesterol in patients with ASCVD through broader access to guideline-directed pharmacotherapy. The project offers a tangible example of how public–private collaboration can accelerate the uptake of innovative therapies in primary care and support national cardiovascular health objectives.

Conclusion: 

Overall, this project serves as a model for multidisciplinary lipid management within primary care, emphasising the importance of collaboration, innovation, and proactive care delivery in addressing the UK’s leading cause of premature death. 

MTW submitted a business case to continue the service offered by this project across Kent. 

References: 

1. National Institute for Health and Care Excellence (NICE). (2023) Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE guideline [NG238]. Available at: https://www.nice.org.uk/guidance/ng238 (Accessed: 3 June 2025).

FA-11523663 | September 2025