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 – 17 months