Project Name: ASCVD and Lipid GP-led Primary Care Model of Care – Collaborative Working Project with TELDOC PCN

Project Summary:

The main objective of the Project 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 Teldoc PCN.   

The CWP will be GP and Clinical pharmacist-led and focus on timely identification of patients with ASCVD including full management reviews and treatment option discussions aiming to achieve:  

  1. Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines 
  2. Identification of ASCVD 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 ASCVD patients 
  4. Counsel and optimise ASCVD patients where appropriate   Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated   
  5. On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably 

Planned Milestones:

  1. Lipid Management pathway/protocol development 
  2. Training by the lead pharmacist on the lipid  pathway and protocol  to all CW Partner pharmacists  
  3. Collection of baseline data, in line with the expected project outcome measurements outlined at the bullet points above
  4. Collection & submission of 3 months clinical activity data. Project Review meeting to discuss project progress. 
  5. Collection & submission of 6 months clinical activity data. Project Review meeting to discuss project progress. 
  6. Collection & submission of 9 months clinical activity data. Project Review meeting to discuss project progress. 
  7. Collection & submission of 12 months clinical activity data.  Project Review meeting to discuss project progress.
  8. Development of business case for sustainable service
  9. Analysis of CWP data, submission of Final CWP 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 and counselling 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 for lipid management, focusing on patients who may have previously not attended GP appointments or been lost to follow-up. This helps to level health inequalities within the GP practices.

Anticipated benefits for partner 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 a Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES
  • Opportunity to show the impact of the CWP to create lasting change in lipid management within the CW Partner

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: November 2022 - 13 months