Project Name: Collaborative Working: County Durham Sub ICB Lipids Collaborative Working Project

Project Summary:

Across County Durham, medicines optimisation priorities are delivered quarterly by primary care pharmacists, nurses and General Practitioners (GPs) via an outcomes based workplan model. The workplan is made up of 8 workstreams each quarter. It is proposed that 1-2 workstreams per quarter would be focused on CVD and lipid optimisation in relation to this project.

Within the scope of this project, every patient identified within the proposed cohort for the quarter will be clinically reviewed and treatment initiated, optimised, or coded appropriately after discussion with the patient.

The County Durham Medicines Optimisation (MO) Team, as part of NENC ICB, will work with the Clinical Digital Reasource Collaborative (CDRC) to utilise the most appropriate clinical searches and digital tools to identify patients and support lipid management in secondary prevention.The CDRC will also support in the reporting of patient numbers and the outcomes of the work across the County Durham practices.

The following workstreams have been identified:

  • Workstream 1/Pre-work: Review of patients with CVD but who are currently not on LLT.  Please note that workstream one will not form part of this collaborative working project as work has commenced outside of the project.

Workstreams in Scope of this project:

  • Workstream 2: Review of patients on low/mod LLT

  • Workstream 3: Patients with high intensity with elevated LDL-C levels

  • Workstream 4: Review of patients not on very high LLT

The agreed phasing of the project will be as follows:

  • Workstream 2: Q1 April – June 2023

  • Workstream 3: Q2 and 3 July – December 2023

  • Workstream 4: Q1 January – June 2024

The main objective of this collaborative working project is to improve the quality of care for patients and support the early identification, review, and pharmacological optimisation of patients with atherosclerotic cardiovascular disease (ASCVD).

Planned Milestones

Collaborative Working: County Durham Sub ICB Lipids Collaborative Working Project milestone table


Expected Benefits:

Anticipated benefits for patients:

  • Reduce health inequalities by ensuring consistent and improved access to lipid management using a NICE-endorsed clinical pathway which will lead to optimal diagnosis and management of ASCVD.
  • Enhanced patient experience of ASCVD with coordinated management of the condition.
  • Appropriate management of ASCVD may reduce the risk of heart attacks and strokes. 
  • Improved access to the most appropriate medication for suitable patients to preserve health and prevent long-term events or mortality.
  • Provide patient tailored support and education to promote adherence with treatment and modifiable risk factors resulting in the optimisation of non-HDL levels.
  • Patient CVD management and lipid optimisation can be provided at a practice level within the local community, supporting the needs of rural populations.

Anticipated benefits for the organisation:

  • Increased proportion of patients receiving appropriate guideline-directed pharmacotherapy.
  • Reduced risk of admissions and re-admissions associated with CVD.
  • Improved population health.
  • Working towards the NHS Long Term Plan and the Core20PLUS5 national NHS approach to support the reduction of health inequalities.
  • Improved clinician knowledge and skills in cholesterol management.
  • Improved confidence and competence in the use of all NICE approved therapies including Novartis' medicines within primary care.

Anticipated benefits for Novartis:

  • Opportunities for the appropriate use of Lipid lowering medicines in line with NICE guidelines, including Novartis’ medicine;
  • Improved reputation; and
  • Improved professional and transparent relationship and trust between Novartis and the NHS.
  • Actioning and supporting national priorities.
  • Working collaboratively across health sectors.

Start Date & Duration: March 2023 for 15 months