Project Name: New Model of Care for Cardiovascular Disease (CVD) Risk and Lipid Management in Primary Care with Mid Hampshire Healthcare GP Federation – Collaborative Working Project

Project Summary:

The main objective of this CWP is to improve the identification of patients at risk of cardiovascular disease and offer a primary care-based, holistic approach to the review and medical optimisation of patients in response to their needs.

The service will focus on timely identifying patients with sub-optimal lipid measures and provide a holistic CVD Risk Assessment appointment to provide patients with the appropriate lifestyle or medical intervention at the earliest opportunity. The service will be led by a multi-disciplinary team, starting with Primary Care Network (PCN) based pharmacists, through to the MHH Federation Healthcare Assistant, Nurse, and GP team.

The service aims to achieve;

  1. Early identification of at-risk patients who have not had intervention in their health and well-being,

  2. Identification of patients, following risk assessment review, of patients who are sub-optimally treated,

  3. Review of treatment options and decision on next steps in collaboration with patients,

  4. On-going patient support and annual review to ensure CVD outcomes improve across the Federation geography.

Planned Milestones:

  1. Patients identified and invited to clinics process policies and pathways in place (eligible)

  2. Collection of baseline data as defined in Metrics to be collected.

  3. Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity. 

  4. Collection of 3 months of clinical activity data

  5. Collection of 6 months clinical activity data

  6. Development of business case

  7. 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 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 HCPs with their lipid management, focusing on patients who may have previously not attended GP appointments or been lost to follow-up. Thus levelling health inequalities within the Federation and PCNs. 

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 the 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:

  • 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 address the problem of health inequalities     
  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation  

Start Date & Duration: July 2022 for 17 months


Project Name: New Model of Care for Cardiovascular Disease (CVD) Risk and Lipid Management in Primary Care – Collaborative Working Project

Partner Organisation(s): Mid Hampshire Healthcare Limited

Completion Date: 11th December 2023

Outcome Summary:

The key aim of this Collaborative working project was to provide an improved primary care secondary prevention service to support enhanced cardiovascular care in our community. The service identified patients with sub optimal lipid measures and offered innovative medical optimisation to improve cholesterol management.

Key Project Outcomes Data:

The service achieved the following outcomes:

  • 1134 patients at risk of a cardiovascular event were identified for lipid management;
  • 200 at risk CVD patients identified as sub-optimally treated for lipid management;
  • 118 CVD patients had a review of their lifestyle/cardiovascular risk factors;
  • 53 CVD patients underwent medicine optimisation (titration of existing medications and alternative treatments options).


This initiative has demonstrated the effectiveness of establishing a community-based secondary prevention service for lipid management, addressing critical challenges within the NHS. Aligned with the proactive approach advocated in the NHS Long Term Plan, the project leveraged additional roles to alleviate primary care workforce capacity challenges.

A noteworthy issue was the substantial number of referrals to secondary care due to Primary Care GP expertise exhaustion in lipid management. The project identified an opportunity to provide an innovative community-based service for these patients, reducing the reliance on face-to-face appointments through remote assessment of medical records.

The use of remote assessment streamlined the review of patients, assessing their cardiovascular disease (CVD) risk, patient record coding, and cholesterol management efficiently. This approach significantly reduced the need for 934 face-to-face appointments, saving time for both clinicians and patients.

CVD risk assessments revealed that patients requiring improved cardiovascular care often had complex needs, necessitating a high level of clinical expertise. Patient feedback underscored their appreciation for the personalised review, assessment, and advice provided.

The project shed light on deficiencies in the FP34 reimbursement mechanism for drugs in Primary Care, prompting collaboration between MHH, Novartis, AHSN, and NHSE at a national level. A resolution is anticipated in the near future.

Additionally, the project identified approximately 4,500 patients without up-to-date lipid profiles, rendering them ineligible for the pathway. Recognising the importance of updated lipid profiles for future service provision, ensuring an accurate understanding of the population's needs is crucial.

By addressing the needs of secondary prevention patients, traditionally lacking access to innovative solutions outside hospitals, the initiative aims to improve outcomes in alignment with national goals. Especially in terms of access to lipid specialists, the project reinforces the potential for continued and expanded services.


This project has demonstrated how secondary prevention can be delivered at pace and scale in a community-based service. 

Current wait times in the Mid Hampshire area are over six months to see a Secondary Care Lipidologist.  It is known that a large proportion of those on this waiting list require only advice and guidance.  Our service demonstrated that through proactive identification of patients we were able to provide an intermediary offering, similar to a Tier 2 model, thereby reducing the burden on Secondary Care and improving patient experience.

A business case has been prepared and submitted to the HIOW ICB for a continuation of this pathway with multiple options to be considered for funding.