Project Name: North Kerrier East PCN Lipid Optimisation Project

Project Summary:

The main objective of the CWP is to improve the quality of care for patients and support the early identification, review, and medical optimization of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner.

  • Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines.
  • Identification of ASCVD patients who have previously not tolerated or refused alternative lipid modification therapies.  
  • Review of treatment options and decision on next steps in collaboration with ASCVD patients.
  • Counsel and optimize ASCVD patients where appropriate, who are at the highest risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance.  Such patients shall be stratified by the CW Partners preferred criteria established in : CVD Prevention: Lipid Pathway – Resources for Health and Care – Health Innovation Manchester. 

Eligible for injectable therapies 
Not on a statin therapy
Not eligible for injectable therapies
On suboptimal statin therapy or dose

  • Early identification of at-risk patients who have not had intervention in their health and wellbeing
  • Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated
  • On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably

Planned Milestones:

  1. Kick off Meeting & Collection of baseline data, in line with the Project Outcome Measures & Data Collection table.
  2. Confirmation of clinical and operational pathway, policy and utilisation of current protocol, and readiness to begin the clinical activity 
  3. Collection & submission of 3 months clinical activity data. Project Review meeting to discuss project progress.
  4. Collection & submission of 6 months clinical activity data. Project Review meeting to discuss project progress.
  5. Collection & submission of 7.5 months clinical activity data. Project Review meeting to discuss project progress.
  6. Development of business case / Case for change 
  7. Analysis of CWP data, submission of Final Project 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 PCN HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, leveling health inequalities within the PCN.

Anticipated benefits for the CW Partner

  • 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 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 addresses the problem of health inequalities. 

  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation  

Start Date & Duration: November 2023 for 8 months.