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 

  • Malling PCN
  • Tunbridge Wells PCN

Planned Milestones:

 Milestone Description
1Kick off meeting
Baseline Data 
2Confirmation of clinical and operational pathway, policy and protocol creation.
3Confirmation of recruitment and on boarding of 1 x 0.2 FTE and 1 x 0.8 FTE Band 8b Clinical Pharmacists
4Clinical Audit and Clinical Audit Discussion with Member Practices
5Collection & submission of 3 months clinical activity data.
6Collection & submission of 6 months clinical activity data.
7Collection & submission of 9 months clinical activity data.
Initiation of development of business case to support service offered by this project
8Collection & submission of 12 months clinical activity data.
9Submission of business case to continue the service offered by this project
10Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary 

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.